Common use of Rejected Clause in Contracts

Rejected. Invalid Receiver ID on EDI Application Form The Receiver ID included on the EDI Application is invalid. Please resubmit with a valid Receiver ID. If you are requesting a Receiver ID, please select the correct “Action Requested” on the EDI Application form. Rejected – Missing Submitter Name on EDI Application Form The Submitter Name is missing on the EDI Application. Please correct and resubmit all forms. Rejected – Invalid Submitter Name on EDI Application Form The Submitter Name on the EDI Application is invalid. Please correct and resubmit all forms. If the request is to change the Submitter Name, please select the correct Action Requested on the EDI Application and resubmit all forms. Rejected – Missing Owner Name on EDI Application Form The Owner Name is missing on the EDI Application. Please correct and resubmit all forms. Rejected – Missing Submitter Address on EDI Application Form The Submitter Address is missing on the EDI Application. Please correct and resubmit all forms. Rejected – Invalid Submitter Address on EDI Application Form The Submitter Address on the EDI Application is invalid. If this is a request to change the Submitter Address, please select the correct Action Requested on the EDI Application and resubmit all forms. Rejected – Missing Type of Submitter on EDI Application Form The type of Submitter is missing on the EDI Application Form. Please correct and resubmit all forms. Rejected – Missing EDI Contact Person on EDI Application Form The EDI Contact Person is missing on the EDI Application Form. Please correct and resubmit all forms. Rejected – Missing Provider Name on EDI Application Form The provider name is missing on the EDI Application. Please correct and resubmit.

Rejected. Invalid Receiver ID Missing NPI on EDI Application Form Agreement The Receiver ID included on the EDI Application is invalid. Please resubmit with a valid Receiver ID. If you are requesting a Receiver ID, please select the correct “Action Requested” on the EDI Application form. Rejected – Missing Submitter Name on EDI Application Form The Submitter Name NPI is missing on the EDI Application. Please correct and resubmit all forms. Rejected – Invalid Submitter NPI on EDI Agreement The NPI on the EDI Agreement is not on the NPI Crosswalk with the legacy PTAN. Please resubmit the forms with a valid NPI. Rejected - Missing Provider Authorization Form The EDI Enrollment Forms were submitted but the Provider Authorization Form was not included. If a Billing Service or Clearinghouse is requesting linkage to a provider, the Provider Authorization Form must be submitted. Please resubmit the EDI Application, the three-page EDI Enrollment Agreement and the Provider Authorization Form. Rejected - Missing Action Requested on Provider Authorization Form The Action Requested was not selected on the Provider Authorization Form. Please correct and resubmit all forms. Rejected – Missing Provider Name on EDI Application Provider Authorization Form The Submitter Provider Name is missing on the Provider Authorization Form. Please correct and resubmit. Rejected – Invalid Provider Name on Provider Authorization Form The Provider Name on the EDI Application Provider Authorization Form is invalid. Please correct and resubmit all forms. If the request name on the form(s) is to change the Submitter Namecorrect, please select contact the correct Action Requested Provider Enrollment department for your Line of Business to update. Rejected – Missing Provider Address on Provider Authorization Form The Provider’s Address is missing on the EDI Application Provider Authorization Form. Please correct and resubmit all forms. Rejected – Invalid Provider Address on Provider Authorization Form The Provider’s Address on the Provider Authorization Form is invalid. If the address on the form is correct, please contact the Provider Enrollment department for your Line of Business to update. Rejected - Missing Owner PTAN (Provider ID) on Provider Authorization Form The PTAN (Provider ID) is missing on the Provider Authorization Form. Please correct and resubmit all forms. Rejected - Invalid PTAN (Provider ID) on Provider Authorization Form The PTAN (Provider ID) on the Provider Authorization Form is invalid. Please resubmit all forms with the correct PTAN (Provider ID). If you do not have this information, please contact the Provider Enrollment department for your Line of Business. Rejected – Missing Group PTAN (Group ID) on Provider Authorization Form Provider number listed is a member of a group. Please resubmit all EDI forms and include the Group PTAN (Group ID) associated with this provider number (PTAN). If you do not have this information, please contact the Provider Enrollment department for your Line of Business. Rejected – Missing NPI on Provider Authorization Form The NPI is missing on the Provider Authorization Form. Please correct and resubmit all forms. Rejected – Invalid NPI on Provider Authorization Form The NPI number on the Provider Authorization Form is not on the NPI Crosswalk with the legacy PTAN. Please resubmit the forms with a valid NPI. Rejected – Missing Name on EDI Application Provider Authorization Form The Owner Name is missing on the Provider Authorization Form. Please include the name of the contact person regarding the Provider Authorization Form and resubmit all forms. Rejected – Invalid Name on Provider Authorization Form The Name listed is not a valid contact Name for the provider listed on the Provider Authorization Form. Please include a valid name of the contact person regarding the Provider Authorization Form and resubmit all forms. Note: The provider/practice name is not an acceptable. Rejected – Missing Original Signature on Provider Authorization Form The Provider Authorization Form was submitted but there was not an original signature included. Please resubmit all pages and include an original signature. Rejected – Missing Submitter Name on Provider Authorization Form The Provider Authorization Form was submitted but the Submitter Name was not included. Please correct and resubmit all forms. Rejected – Invalid Submitter Name on Provider Authorization Form The Submitter Name listed must be associated with the Submitter ID listed on the EDI Application. Please correct and resubmit all forms. Rejected – Missing Submitter Address on EDI Application Software Order Form The EDI Enrollment Forms were submitted but the Software Order Form was not included. You must submit a completed Software Order Form when requesting software. Please resubmit all forms. Rejected - Missing PTAN (Provider ID) on Software Order Form The PTAN (Provider ID) is missing on the Software Order Form. Please correct and resubmit all forms. Rejected - Invalid PTAN (Provider ID) on Software Order Form The PTAN (Provider ID) on the Software Order Form is invalid. Please resubmit all forms with the correct PTAN (Provider ID). If you do not have this information, please contact the Provider Enrollment department for your Line of Business. Rejected – Missing NPI on Software Order Form The NPI is missing on the Software Order Form. Please correct and resubmit all forms. Rejected – Invalid NPI on Software Order Form The NPI on the Software Order Form is not on the NPI Crosswalk with the legacy PTAN. Please resubmit the forms with a valid NPI. Rejected – Missing Submitter Address ID on Software Order Form The option to Submit Claims was selected but the Submitter ID is missing on the EDI Application. Please correct and resubmit all forms. Rejected – Invalid If you are requesting a Submitter Address on EDI Application Form The Submitter Address on the EDI Application is invalid. If this is a request to change the Submitter AddressID, please select the correct “Action Requested Requested” on the EDI Application and resubmit all forms. Rejected – Missing Type of Submitter on EDI Application Form The type of Submitter is missing on the EDI Application Form. Please correct and resubmit all forms. Rejected – Missing EDI Contact Person on EDI Application Form The EDI Contact Person is missing on the EDI Application Form. Please correct and resubmit all forms. Rejected – Missing Provider Name on EDI Application Form The provider name is missing on the EDI Application. Please correct and resubmitform.