New Custom Claim Edits

Date: October 27, 2025

Attention: All Providers

Effective date: November 5, 2025

Call to action: The purpose of this communication is to inform providers and their designated clearinghouses of the new custom edits scheduled to go live on November 2025. These edits will reject claims before they enter our claims adjudication system if the submitted data does not meet required standards.

How rejections will be communicated:

When a claim is rejected, you will receive a 277CA (Claim Acknowledgment) transaction with the rejection reason.
The rejection reason will be displayed in Loop 2220D, STC segment, element STC12.
The 277CA will be sent to the same entity that currently receives payer rejections today (e.g., your clearinghouse or billing service).

New edits that will cause rejections:

Billing Provider Tax ID
- Billing Provider tax ID must be submitted in the correct format per 5010 requirements.
Autism Services
- Autism services must be submitted with valid data elements including, CPT code, client age, rendering provider taxonomy, diagnosis code and billing provider entity type.
Zip Code
- Zip Codes must be submitted in the correct format per 5010 requirements. (5-digit or 9-digit)
Invalid Frequency Code
- UB04 and CMS claims must be submitted with the correct frequency code.
Patient Loop
- Patient Loop 2000C is invalid and should not be submitted.
Service Facility Address
- Service Facility address must be submitted with a physical address. (no PO Boxes)

Next step for Providers: Providers should share this communication with their billing staff and clearinghouse.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.