Claim not covered by this payer/contractor.  You must send the claim to the correct payer/contractor.  

Avoiding/Correcting This Error

This denial is received when your Medicare patient is enrolled in a MA plan, instead of “traditional fee-for-service” Medicare.

MA plans are health plans offered by private companies approved by Medicare that replaces a beneficiary's traditional Medicare plan.

When actively enrolled into an MA Plan, please submit the patient's Medicare claims to that MA Plan.

Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan.

Missing/incomplete/invalid procedure code.

Avoiding/Correcting This Error

The CPT/HCPCS code reported is not valid for the date(s) of service billed on the claim. This may also mean that the digits or alpha characters in the code are incorrectly reported.

Please review the claim and check the status of the CPT/HCPCS code in question. Submit the claim again when you have the correct code, or the correct digits/alpha for the code.

Claim/service lacks information or has submission/billing error(s).

N822:
Missing procedure modifiers(s).

Avoiding/Correcting This Error

We were unable to process this claim do it missing a required modifier for the CPT submitted.

Please review a full listing of Modifiers Used in CMS-1500 Claim Reporting and append the appropriate modifier and resubmit the claim.

Note: Since, this is considered a rejection you will not have the option to reopen the claim.

This care may be covered by another payer per coordination of benefits.

Avoiding/Correcting This Error

During patient registration, it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare.

Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer.

This care may be covered by another payer per coordination of benefits.

Avoiding/Correcting This Error

During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare.

Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer.

This non-payable code is for required reporting only.

Avoiding/Correcting This Error

This is not an error. The CPT/HCPCS code reported is used for reporting purposes only. These reporting codes are given by CMS for providers to use when documenting certain incentive plans, etc.

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Service not payable with other service rendered on the same date.

Avoiding/Correcting This Error

This would apply to the following scenarios:

• MPFSDB status B codes
• Status E drug codes that should be considered bundled
• MPFSDB status X drug codes
• DME codes that should be considered bundled
• MPFSDB status T codes that are billed with MPFSDB status A, C or D codes on the same DOS/same rendering provider and when a rendering provider performs both the surgical procedure and anesthesia on the same DOS.

The CPT/HCPCS submitted on the claim is considered a bundled code per the MPFSDB.

Review the claim submission to ensure the correct CPT/HCPCS was entered. If there was a clerical error and the incorrect CPT/HCPCS was entered, make the correction through a reopening request.

The verification of the bundled CPT/HCPCS can be done by accessing the MPFSDB/DMEPOS Fee Schedule.

This provider was not certified/eligible to be paid for this procedure/service on this date of service.

Avoiding/Correcting This Error

There is an issue with the billing and/or rendering provider credentialing information per provider enrollment, provider information submitted on the claim and/or or the services provided are not allowed per the providers specialty/credentials.

This could reflect a number of possible issues. It is important to verify the information submitted on the claims and to verify the credentialing via PECOS.

The following scenarios would apply:

• The billing provider number contains something other than alpha or numeric characters.
• The billing provider PIN field is blank.
• Claim detail from date of service is prior to the billing provider's Medicare effective date if the Medicare effective date is present on the provider file.
• Claim detail from date of service is prior to the performing (detail) provider's Medicare effective date if the detail provider's Medicare effective date is present on the provider file.
• The services were performed prior to the provider’s certification date.
• Provider A/R 52 - ERP (EDUCATION RECOGNITION PROGRAM) certificate must be on file for codes G0108 and G0109 to be billed.
• A procedure code is not set up for the performing provider type and/or specialty reported.
• Certain radiology restrictions for X-rays billed by provider type 38 in the wrong state.
• Exception for NY State, which requires certification for nurse practitioners to perform assistant-at-surgery services. This does not apply to CT or any J6 or JK NE states.
• If the rendering provider NPI (REND-NPI) field and the rendering provider PIN (REND-PROV) field are both populated, but do not have a valid relationship.
• Specialty 69 with place of service 60 being billed.
• IDTF providers can only bill procedures that they submit on their initial/updated provider enrollment application. If not set up it will be denied.
• If provider has one of the below A/R codes on provider enrollment file:
  • A/R 31 = Provider retired
  • A/R 32 = Provider moved out of state
  • A/R 39 = Provider resigned (C.P.S. - Voluntary - Board of Registration - CMS)
  • A/R 38 = Provider Deceased
  • A/R 36 = Suspend - Social Security Administration (SSA) review
  • A/R 37 = Suspend - Pay Medicare non-assigned
  • A/R 42 = New group - pending Medicare B approval and profile transfer
  • A/R 43 = Group not approved for Medicare B reimbursement
  • A/R 46 = INACTIVE PROVIDER = Action Reason on PE file used when PE enrollment status is inactive, or provider is end-dated

  • A/R 72 = was created for the deactivation of those providers who have not billed Medicare for 12 consecutive months

This provider was not certified/eligible to be paid for this procedure/service on this date of service.

Avoiding/Correcting This Error

The billing or rendering provider NPI is not actively enrolled with Medicare on the date(s) of service billed on the claim. Please verify the provider's Medicare effective date in PECOS. If the provider shows active now, the claim may be resubmitted. If the provider is not active, please contact our Provider Enrollment call center to discuss what actions are needed to ensure the provider is properly enrolled in Medicare Part B. Jurisdiction JK: 888-379-3807

Claim not covered by this payer/contractor.  You must send the claim to the correct payer/contractor.  

Avoiding/Correcting This Error

This denial is received when your Medicare patient is enrolled in a MA plan, instead of “traditional fee-for-service” Medicare.

MA plans are health plans offered by private companies approved by Medicare that replaces a beneficiary's traditional Medicare plan.

When actively enrolled into an MA Plan, please submit the patient's Medicare claims to that MA Plan.

Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan.

Exact duplicate claim/service.

Avoiding/Correcting This Error

A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the:

• same beneficiary; for the
• same item(s) or service(s); for the
• same date(s) of service.

If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. This can occur even if the original claim is in a processing status waiting to be paid. 

It is critical that you do not resubmit another claim until you know the status of your original submission. If you haven’t received your RA, and you submit claim(s) again, you may receive the duplicate claim denial before you receive the RA for the first submission detailing the payment or denial of services. 

Electronic Claim Submitter Tips:

• Check your EDI validation report to verify your claims were received and accepted or which claims may have rejected. If you are unsure how to check these reports, contact the EDI Help Desk at 877-273-4334.
• Do not set up your claims software system to automatically rebill Medicare claims.
  • Before resubmitting Medicare claims, verify the claim status by utilizing NGSConnex/IVR system.
• Ensure that your claims batching process is functioning properly.

Remittance Advice Tips:

• Pay close attention to your RA to determine if the denied claim(s) should be resubmitted or appealed.
• Make sure that your billing staff or third-party billing service knows the Medicare payment floors standards.

Exact duplicate claim/service.

Avoiding/Correcting This Error

A duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the:

• same beneficiary; for the
• same item(s) or service(s); for the
• same date(s) of service.

If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. This can occur even if the original claim is in a processing status waiting to be paid. 

It is critical that you do not resubmit another claim until you know the status of your original submission. If you haven’t received your RA, and you submit claim(s) again, you may receive the duplicate claim denial before you receive the RA for the first submission detailing the payment or denial of services. 

Electronic Claim Submitter Tips:

• Check your EDI validation report to verify your claims were received and accepted or which claims may have rejected. If you are unsure how to check these reports, contact the EDI Help Desk at 877-273-4334.
• Do not set up your claims software system to automatically rebill Medicare claims.
  • Before resubmitting Medicare claims, verify the claim status by utilizing NGSConnex/IVR system.
• Ensure that your claims batching process is functioning properly.

Remittance Advice Tips:

• Pay close attention to your RA to determine if the denied claim(s) should be resubmitted or appealed.
• Make sure that your billing staff or third-party billing service knows the Medicare payment floor standards.

Patient cannot be identified as our insured.

Avoiding/Correcting This Error

Services were denied for one or more of the following reasons:

• The name or Medicare number was incorrect or missing.
• The date of death precedes the date of service.
• Expenses were incurred prior to coverage.
• Expenses were incurred after coverage terminated.

To reduce or eliminate these types of claim denials, patient screening is vital to an office’s success in obtaining the essential information needed for correct claim submission.

Office personnel should obtain additional patient information when registering patients. This can be accomplished by having your patient complete a medical information/history and insurance information form. Also, pay close attention to:

• Patient's full name direction from the Medicare ID card.
• Patient address and phone number.
• Obtain the name and identification numbers of other insurance (Medicare or other type of insurance plan involved).
  • Photocopying of all health insurance cards is recommended.
• Patient’s date of birth

Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information.

This service/equipment/drug is not covered under the patient's current benefit plan.

Avoiding/Correcting This Error

Medicare Fee-for-Service does not cover the service that has been billed for the condition.

The CPT/HCPCS on the claim is not a covered Medicare service/equipment or drug.

There are multiple reasons for denial which includes the following, but is not limited to:

• Status A Code
• Status R Code
• Status X Code

To avoid future denials please use the following resources, as well as the most current CPT/HCPCS coding books, to verify if the code you want to bill to Medicare is a covered service:

• Medicare Physician Fee Schedule Database (MPDB)
• CMS Internet Only Manual (IOM)
• Medicare Coverage Data Base

This service/equipment/drug is not covered under the patient's current benefit plan.

Avoiding/Correcting This Error

Medicare Fee-for-Service does not cover the service that has been billed for the condition.  

The time limit for filing has expired.

Remark Code N211

Alert: You may not appeal this decision.

Avoiding/Correcting This Error

Providers must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service.

The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made.

CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year if the provider can show good cause for the delay.

The time limit for filing has expired.

Remark Code N211
Alert: You may not appeal this decision.

Avoiding/Correcting This Error

Providers must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service.

The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made.

CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year if the provider can show good cause for the delay.

Patient cannot be identified as our insured.

Avoiding/Correcting This Error

Services were denied for one or more of the following reasons:

• The name or Medicare number was incorrect or missing.
• The date of death precedes the date of service.
• Expenses were incurred prior to coverage.
• Expenses were incurred after coverage terminated.

To reduce or eliminate these types of claim denials, patient screening is vital to an office’s success in obtaining the essential information needed for correct claim submission.

Office personnel should obtain additional patient information when registering patients.

Usually this is accomplished by the patient completing a medical information/history and insurance information form. Pay close attention to:

• Patient’s full name directly from the Medicare ID card.
• Patient address and phone number.
• Name and identification numbers of other insurance (Medicare or other type of insurance plan involved).
  • Photocopying of all health insurance cards is recommended.
• Patient’s date of birth.

Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information.

These are noncovered services because this is not deemed a 'medical necessity' by the payer.

Avoiding/Correcting This Error

The CPT/HCPCS code reported is not covered for the beneficiary, and the beneficiary is liable for these charges. If you have reported an incorrect code, or forgot a modifier, the claim will need to be reviewed as a reopening or a redetermination.

Patient is enrolled in a Hospice. 

Avoiding/Correcting This Error

When a Medicare beneficiary, or their authorized representative elects hospice all services related to the patient's terminal condition are handled by the hospice and not billed to Medicare Part B. If the patient requires care unrelated to their terminal condition, a Medicare provider may bill that service to Medicare, and ensure modifier GW is appended to the CPT/HCPCS code being billed. The physician who is the attending physician for the patient's hospice care may bill their claims to Medicare Part B with modifier GV appended to the CPT/HCPCS code being billed

For home health claims (32X), the attending physician on the PECOS physician file has a termination date present and it is equal to or less than the claim from date of service.

Avoiding/Correcting This Error

The attending physician reported on your claim must be active in PECOS to be considered a valid attending physician for the home health patient.

Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer.

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct: reformat as secondary and resubmit.

If the records are incorrect, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):

• Telephone: 855-798-2627
• TTY/TDD: 855-797-2627 (for hearing and speech impaired),

Medicare ‒ MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897

Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer.

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct, reformat as secondary and resubmit.

If records are not correct and you have information that disputes the records, please contact the Benefits Coordination & Recovery Center:

Medicare - MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897

Telephone number: 855-798-2627

Hospice: Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer.

Avoiding/Correcting This Error

If this is correct: Follow MSP billing guidelines and submit the claim accordingly.

If this is incorrect: As part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records - we are not the Medicare office that manages those files. Please contact the BCRC:

Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays)

• Telephone: 855-798-2627 or
• TTY/TDD: 855-797-2627 (for hearing and speech impaired)

Address for general MSP correspondence:
Medicare – MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897

Fax: 405-869-3307

In addition, providers should utilize all available/applicable condition codes, occurrence codes and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF.

Related Content

• Medicare Secondary Payer

The claim was submitted as Medicare primary and a positive working aged record exists at CWF.

Avoiding/Correcting This Error

The claim should be billed to the primary insurer. If records are correct, reformat and resubmit as secondary. If you have information that disputes open records, please contact the BCRC at 855-798-2627.

Related Content

• MSP information is available on our website under the Claims & Appeals tab, then under Claims; also view the article “Prevent an MSP Rejection on a Medicare Primary Claim” within the MSP section.

The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date).

Avoiding/Correcting This Error

• If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, you may submit an adjustment (TOB XX7) to this claim to change it to an MSP claim.
• If the MSP record is incorrect because the beneficiary and/or spouse retired, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed) and code the beneficiary’s retirement date with OC 18 and/or the spouse’s retirement date with OC 19.  
• If the MSP record is incorrect, because of a reason other than retirement, contact the BCRC to request the record be updated. Follow instructions in CMS’ article SE1416 (which may require you to fax the BCRC). Once the BCRC updates the MSP record, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed).

Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates.  

Related Content

• Medicare Secondary Payer on our website has information on:
  • Collecting and reporting retirement dates on Medicare claims
  • Contacting the BCRC, refer to Correct a Beneficiary’s MSP Record
  • Correcting or adjusting a claim due to an MSP-related issue
  • Preventing an MSP rejection on a Medicare primary claim

Claim submitted as Medicare primary and a positive disability record exists at CWF. This claim should be submitted to the primary insurer.

Avoiding/Correcting This Error

If the records are correct, reformat as Medicare secondary; the Medicare Secondary Payer page on our website provides direction.

If the records need to be updated, you will need to contact the BCRC at 855-798-2627 or written inquiry:

MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897

Claim submitted as Medicare primary and a positive disability record exists at CWF.

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct: reformat as secondary and resubmit.

If records are not correct and you have information that disputes the records, please contact the BCRC:

Medicare - Coordination of Benefits
P.O. Box 33847
Detroit, MI 48232

Toll free: 800-999-1118

You can find additional information on VA transfers in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 60. (319 KB)

The covered charges or reimbursement is greater than 0, however, one of the following is true:

• The attending physician NPI on the claim is not present in the eligible attending physician file from PECOS
• The attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the first four letters of the last name of the attending physician on the claim does not match the first four letters of the last name of the NPI record in the eligible attending physician files from PECOS
• The specialty code is not a valid physician specialty code

*Note: The first name is no longer evaluated as part of the matching criteria. Additionally, any special characters in the last name will be ignored.

Avoiding/Correcting This Error

Verify eligibility of the attending/ordering physicians in PECOS. Print that verification and make it part of the medical record. If applicable, submit a reopen request to the Appeals Department indicating error and the correction needed.

This claim is a duplicate of a previously submitted home health claim. The first two positions of the TOB are 32X, 33X or 34X and the following fields on the history and processing claim are the same.

• MBI
• Provider number
• Statement ‘from’ date of service
• Statement ‘thru’ date of service
• Revenue code
• HCPCS and modifiers (if required by Revenue Code File)

Avoiding/Correcting This Error

Check your remittance advice or the claims processing system for a previously submitted/processed claim before submitting any new billing.

FQHC PPS claim with a LIDOS that matches another LIDOS on a previously submitted claim and all of the following match:

• MBI
• Provider number
• LIDOS

If appropriate make corrects and resubmit a new claim to the MAC.

Avoiding/Correcting This Error

Before submission of the claim, ensure that no other claim was previously billed and processed with the same line item date of service. If another claim was processed with the same line item date of service, an adjustment to the processed claim will need to be submitted as an XX7 type of bill to include all charges for claim.

This FQHC PPS claim reports a line item DOS that matches another line item DOS on a previously submitted claim for the same beneficiary.

Avoiding/Correcting This Error

Make sure services provided are submitted for reimbursement once. If additional services need to be added to a submitted claim, wait for that claim to process. Then adjust the processed claim to add the additional services.

The requested nonmedical information was not received timely.

Avoiding/Correcting This Error

To have this claim considered for payment submit a new electronic billing with the requested information.

Each line of charges on this claim has been denied by medical review.

Avoiding/Correcting This Error

To access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree with the denial, you have the right to appeal.

Each line of charges on this claim has been denied by medical review.

Avoiding/Correcting This Error

To access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree with the denial, you have the right to appeal.

Each line of charges on this claim has been rejected and/or rejected and denied.

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, return to the claim and follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field on MAP171D.
2. Utilize the “SC” field to access the reason code file (17)
3. Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

Each line of charges on this claim has been rejected and/or rejected and denied

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field
2. Press <F1>/<PF1> to access the reason code file
3. Key the line item reason code over the claim level reason code and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

Related Content

• Reminder on Deleting Revenue Code Lines in the Fiscal Intermediary Standard System Direct Data Entry System

All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability.

Avoiding/Correcting This Error

Verify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field on MAP171D.
2. Utilize the “SC” field to access the reason code file (17)
3. Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability.

Avoiding/Correcting This Error

Verify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field on MAP171D.
2. Utilize the “SC” field to access the reason code file (17)
3. Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

All the line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an ABN.

Avoiding/Correcting This Error

You have the right to submit an appeal when you believe the medical records support that the denied services were reasonable and medically necessary.

Providers should review the information on the CMS website for Medically Unlikely Edits prior to claim submission. If the units rendered are in excess of the allowed units for that service, consider whether the excess units were actually rendered and billed correctly.

Related Content

• Medically Unlikely Edits and FAQs
• Appeals section
• Medicare Parts A & B Appeals Process

Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes.

Avoiding/Correcting This Error

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered.

Providers can visit the CMS Medicare Coverage Database (MCD) to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials.

This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed).

Avoiding/Correcting This Error

Review coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity. 

When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:

• the dates of service being requested
• a list of documentation to submit

To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit

If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal.

Related Content

• Appeals section of our website

The service date(s) on this claim overlap a hospice election period and condition code 07 is not present.

Avoiding/Correcting This Error

If services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient).

Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex.

If appropriate, make corrections and resubmit a new claim.

The service date(s) on this claim overlap a hospice election period and condition code 07 is not present.

Avoiding/Correcting This Error

Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex.

If services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient).

If services are related, submit the claim to the hospice agency.

Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank.

Avoiding/Correcting This Error

There was an issue with NOAs incorrectly editing for U537F. Once the system was fixed, NOAs could be resubmitted and subsequently processed.

NOAs submitted late due to this issue may have affected more than one period of care claim. All claims affected should be submitted with modifier KX appended to the HIPPS code on the 0023 revenue line and Remarks specifying the request for exception to the late NOA penalty.

Hospice: This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:

1. Statement ‘from’ and ‘through’ dates overlap
2. Provider numbers are the same
3. At least one revenue code line matches
4. The diagnosis code(s) on both the history and incoming claim are the same
5. If the history or incoming claim has one of the following HCPCS modifiers LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9 for the same HCPCS, and same date of service, and the incoming or history claim has a blank HCPCS modifier, or the HCPCS modifier isn’t equal to LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9
6. At least one HCPCS code is the same on both claims or
7. If HCPCS modifier (LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9) are equal on both the incoming and history claim, the reason code will assign

Avoiding/Correcting This Error

Verify the ‘from’ and ‘through’ dates, provider number, revenue codes, HCPCS codes, and line item date of service on the bill.

If the claim is truly a duplicate; no action is necessary. Providers should develop and implement a process to ensure that duplicate claims are not being submitted.

If all information is correct, add the charges from the incoming claim to those of the paid claim by submit an adjustment to the processed claim.

Hospice: This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:

1. The ‘statement covers period’ is the same on both bills
2. Provider numbers are the same
3. At least one revenue code or one HCPCS code is the same on both bills
4. At least one diagnosis code matches on both claims and
5. At least one line item date of service for lab charges is the same on both claims

Avoiding/Correcting This Error

Providers should develop and implement a process to ensure that duplicate claims are not being submitted.

• If the claim is truly a duplicate, no action is necessary.
• If this is not a duplicate and the provider is trying to add information to the original claim, submit an adjustment to the processed claim.

Hospice: This outpatient claim contains service dates that equal or overlap a previously submitted outpatient claim from your facility. At least one of the revenue codes or HCPCS codes match.

Avoiding/Correcting This Error

Providers should develop and implement a process to ensure that duplicate claims are not being submitted.

• Verify the ‘from’ and ‘through’ dates, provider number, revenue codes, HCPCS codes and diagnosis codes on the bill
• If the claim is truly a duplicate, no action is necessary
• If all information is correct, add the charges from the incoming claim to those of the paid claim by submitting an adjustment to the processed claim

Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code.

Avoiding/Correcting This Error

• Verify the claim history to determine the period of care claim that is causing the overlap
• If there are services that should have been included on a processed/paid claim, you must submit an adjustment (3X7 bill type) to add any services not originally included on the claim
• All services provided to a beneficiary within the home health period of care must be submitted on one claim

Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code.

Avoiding/Correcting This Error

• Verify the claim history using the FFS/DDE Provider Online system, your remittance advice and/or the CWF to determine the episode claim that is causing the overlap
• If there are services that should have been included on a processed/paid episode claim, you must submit an adjustment (3X7 bill type) to add any services which were not originally included on the claim
• All services provided to a beneficiary within the home health episode must be submitted on one claim.

Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:

• MBI
• TOB (all three positions of any TOB)
• Provider number
• Statement ‘from’ date of service
• Statement ‘through’ date of service
• Total charges (0001 revenue line)
• Revenue code
• HCPCS and modifiers (if required by revenue code file)

Avoiding/Correcting This Error

This reason code may be applied when an NOA and period of care claim are submitted at the same time or when an NOA and one is already in the system.

If the NOA and claim were submitted at the same time, and no NOA has yet been processed for the admission period, resubmit the NOA and wait for it to process before submitting the claim.

If the NOA already on the system needs to be corrected, cancel the processed NOA and after it has canceled, submit the NOA with the corrected information.

Home Health and Hospice: Each line of charges on this claim has been rejected and/or rejected and denied.

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Providers can see line details in NGSConnex and hover over the line item reason code(s) for details. You can access MAP171D for line item detail information:

• Hit F2 once or F11 twice from page 2 of the claim to access MAP171D.
  Since it is possible for each line item to have a different line item reason code, review the additional lines that were rejected. To perform this function, F6 to forward to the next claim line and F5 to go back through previous claim lines.

Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility.

Avoiding/Correcting This Error

You can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:

• Hit <F2>/<PF2> once or <F11>/<PF11> twice from Claim Page 02 of the claim to access MAP171D
• Since it is possible for each line item to have a different line item reason code, review the additional lines that were rejected
• To perform this function, <F6>/<PF6> to forward to the next claim line and <F5>/<PF5> to go back through previous claim lines

Hospice: CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Verify that the MBI on the claim is for the correct beneficiary.

• If the MBI is correct, verify the beneficiary’s entitlement information, correct, and resubmit if appropriate.
• If the MBI is incorrect, submit a new bill with the correct MBI.
• If you are billing for a rejection in order to bill another insurer, you have accomplished what you wished to do.

Home Health and Hospice: The statement from/through date is greater than the date of death on the beneficiary master record.

Avoiding/Correcting This Error

Verify the MBI and dates of service.

• If appropriate, correct the information and submit a new claim or update returned claim.
• If the actual date of death was reported in error to the Social Security office, that office must be contacted to correct the date.
• If the beneficiary is still alive, he/she must contact Social Security for an interview as these cases cannot be corrected through the MAC.

Home Health: The services on this claim fall within or overlap an MA HMO enrollment period.

Avoiding/Correcting This Error

Collect all insurance information from the beneficiary when admitted to your HHA. Talk to the beneficiary about insurance changes and check CWF before billing Medicare. Many times a claim will overlap an MAO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim.

Hospice: The dates of service reported on this claim are a duplicate to a claim with the same dates of service that has previously processed. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Providers should develop and implement a process to ensure that duplicate claims are not being submitted.

• If the claim is truly a duplicate, no action is necessary
• If this is not a duplicate and the provider is trying to add information to the original claim, submit an adjustment to the processed claim
  • Note: Hospice room and board denials must be submitted with revenue code 0659, HCPCS code A9270 and a ‘GY’ modifier

Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank.

Avoiding/Correcting This Error

There was an issue with NOAs incorrectly editing for U537F. Once the system was fixed, NOAs could be resubmitted and subsequently processed.

NOAs submitted late due to this issue may have affected more than one period of care claim. All claims affected should be submitted with modifier KX appended to the HIPPS code on the 0023 revenue line and Remarks specifying the request for exception to the late NOA penalty.

Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code.

Avoiding/Correcting This Error

• Verify the claim history using the FFS/DDE Provider Online system, your remittance advice and/or the CWF to determine the episode claim that is causing the overlap
• If there are services that should have been included on a processed/paid episode claim, you must submit an adjustment (3X7 bill type) to add any services which were not originally included on the claim
• All services provided to a beneficiary within the home health episode must be submitted on one claim.

Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:

• MBI
• TOB (all three positions of any TOB)
• Provider number
• Statement ‘from’ date of service
• Statement ‘through’ date of service
• Total charges (0001 revenue line)
• Revenue code
• HCPCS and modifiers (if required by revenue code file)

Avoiding/Correcting This Error

This reason code may be applied when an NOA and period of care claim are submitted at the same time or when an NOA and one is already in the system.

If the NOA and claim were submitted at the same time, and no NOA has yet been processed for the admission period, resubmit the NOA and wait for it to process before submitting the claim.

If the NOA already on the system needs to be corrected, cancel the processed NOA and after it has canceled, submit the NOA with the corrected information.

Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility.

Avoiding/Correcting This Error

You can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:

• Hit <F2>/<PF2> once or <F11>/<PF11> twice from Claim Page 02 of the claim to access MAP171D
• Since it is possible for each line item to have a different line item reason code, review the additional lines that were rejected
• To perform this function, <F6>/<PF6> to forward to the next claim line and <F5>/<PF5> to go back through previous claim lines

CMS' records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS DDE Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission.

The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Verify that the MBI on the claim is for the correct beneficiary.

• If the MBI is correct, verify the beneficiary’s entitlement information, correct, and resubmit if appropriate.
• If the MBI is incorrect, submit a new bill with the correct MBI.
• If you are billing for a rejection in order to bill another insurer, you have accomplished what you wished to do.

The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Verify that the MBI on the claim is for the correct beneficiary.

• If the MBI is correct, verify the beneficiary’s entitlement information, correct, and resubmit if appropriate.
• If the MBI is incorrect, submit a new bill with the correct MBI.
• If you are billing for a rejection in order to bill another insurer, you have accomplished what you wished to do.

The services billed on the claim were provided prior to the date the beneficiary was entitled to Medicare coverage. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Verify the MBI and date(s) of service. If services were provided prior to the date the beneficiary was entitled to Medicare, no further action is necessary. Otherwise, correct and resubmit.

The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period.

Avoiding/Correcting This Error

Verify the admission date, from and through dates on the claim and compare the dates to the HMO entitlement dates.

• Outpatient facilities and IPPS and IRF hospitals, or LTCH billing services within an HMO enrollment period must be submitted directly to the appropriate HMO contractor.
• Verify HMO/MAO enrollment prior to claim submission by reviewing the CWF, the IVR system and FISS/DDE Provider Online System or NGSConnex.
• Non-PPS inpatient hospital or inpatient SNF services which overlap either the effective or termination date of the HMO period will need to be split. Submit services rendered during the HMO enrollment period to the appropriate HMO contractor. Submit services rendered outside of the HMO enrollment period to the MAC.
  • IPPS, IRF, and LTCH claims and covered SNF services during the HMO enrollment period should be submitted to the MAC in order to post an informational no-pay encounter claim. It is necessary for these days to be captured by the CMS in the DSH or LIP for IRF calculations and to take benefit days from the spell of illness on the CWF.
  • IPPS acute care teaching hospitals billing for IME payment must bill with both a condition code 04 and 69 with covered charges.
  • Effective with discharges on or after 10/1/2006, non-teaching IPPS hospitals, IRFs and LTCHs are required to submit informational no-pay encounter bills. These nonteaching hospitals are required to submit claim with covered charges and a condition code 04. Effective July 2012, IRF providers must use an appropriate HIPPS code based on the PAI assessment accompanied by an occurrence code 50 and the corresponding assessment date when submitting no-pay claims.
  • Effective 1/1/2008, all SNF-covered services during an HMO enrollment period must be billed using condition code 04 with covered charges in order to post the no-pay encounter claim. No claim should be submitted to the MAC for noncovered SNF stays or for dates of service prior to 1/1/2008.

The services on this claim fall within or overlap an MA HMO enrollment period.

Avoiding/Correcting This Error

Verify the admission date, from, and through dates on the claim and compare the dates to the MAO/HMO entitlement dates.

• Outpatient facilities services within an HMO enrollment period must be submitted directly to the appropriate HMO contractor.
• Verify HMO/MAO enrollment prior to claim submission by reviewing the CWF, the IVR system and FISS DDE Provider Online System or NGSConnex.

Revenue code 519 is present and the beneficiary is not enrolled in a Medicare advantage plan under option code 'A', 'B', OR 'C'.

Avoiding/Correcting This Error

Review your beneficiary’s enrollment in a Medicare HMO/MAO prior to providing services. A beneficiary may drop MAO coverage; review the CWF, IVR, NGSConnex, or HETS to identify a termination date for the MAO plan.

Related Content

• Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
   

Services billed while beneficiary is unlawfully present in the United States.

Avoiding/Correcting This Error

Medicare does not pay for medical items/services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service that the items/services were furnished.

Related Content

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements, Section 10.5 - Claims Processing Requirements for Deported Beneficiaries
 

The HCPCS on the revenue code line has a status code of 'M', but the TOB is not equal to 85X.

Avoiding/Correcting This Error

Change TOB to 85X.

For the specific type of bills listed, the claim contains one or more revenue codes that are not valid for the type of bill:

1. TOB IS 71X, Provider range 3400‒3499, 3800‒3999, 8500‒8899
   (FACILITY TYPE = M) OR 8900‒8999 (FACILITY TYPE =S) and revenue code other than 521, 522, 900 or 780 with line item DOS on or after 4/1/2005 is billed.
2. TOB IS 71X, Provider range 3400‒3499, 3800‒3999, 8500‒8899
   (FACILITY TYPE = M) OR 8900-8999 (FACILITY TYPE = S) and revenue code other than 521, 522, 524, 525, 527, 528, 780 or 900 with line item DOS on or after 7/1/2006 is billed.;
3. TOB IS 73X, Provider range 1800‒1899 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item DOS on or after 4/1/2005 and prior to 4/1/2010 is billed.
4. TOB IS 73X, Provider range 1000‒1199 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item DOS on or after 4/1/2005 and prior to 4/10/2010 is billed.
5. Revenue codes 520, 521, 522, 780 and 900 can only be billed with one unit per revenue code line for dates of service on or after 4/1/2005.
6. TOB IS 71X, 73X OR 77X and there is no line item DOS on a line.
7. TOB IS 77X, Provider range 1000‒1199 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 OR 900 with line item DOS on or after 4/1/2010.
8. TOB IS 77X, Provider range 1800‒1989 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item DOS on or after 4/1/2010.

All references to TOB 73X now apply to TOB 77X.

Avoiding/Correcting This Error

Providers can utilize the FISS DDE system and check Option 01/13 revenue code file and find the type of bill that is applicable to their claim. The system will have a “Y” or “N” indication as to whether the revenue code is allowed for the type of claim.

Verify billing and if appropriate, correct.

The claim lines contain one or more revenue codes that are not valid for type of bill 77X:

• There is no line item DOS on a line.
• Provider number (PTAN) range is XX1000‒XX1199 (FACILITY TYPE = S OR M) and revenue code is other than 52X, 78X OR 900.
• Provider number (PTAN) range is XX1800‒XX1989 (FACILITY TYPE = S OR M) and revenue code is other than 52X, 78X or 900.

Avoiding/Correcting This Error

Ensure that your FQHC claim follows billing requirements for PPS reimbursement. Report a billable encounter revenue code (52X, 78X, or 900) on payment code lines and qualifying visit HCPCS code lines. Claim lines reporting incident-to services should be billed using non-billable encounter revenue codes.

Verify billing and if appropriate, correct.

A revenue code is present in the line item being edited, but the total charges associated with that line item are blank or equal to zero.

For claims with DOS on/after 4/1/2010, detailed line-item reporting is required. Services provided incident to the encounter should report a non billable encounter revenue code and actual charges.

AIR: The claim’s encounter line revenue code should reflect a clinic visit (520), mental health visit (0900), or telehealth visit (0780) and include all charges incurred during the encounter.

PPS: The claim’s encounter line revenue code should reflect a clinic visit (520) or mental health visit (0900) and include charges determined by the facility to reflect payment code charges.

Avoiding/Correcting This Error

Use claim correction option to update claim, if appropriate.

When billing for the administration of influenza, hepatitis, or pneumococcal vaccine, you must report the HCPCS code in conjunction with revenue code 771. This applies to the administration of influenza virus vaccine HCPCS code G0008, the administration of pneumococcal vaccine HCPCS code G0009, the administration of hepatitis b vaccine HCPCS code G0010, or the Influenza A (H1N1) immunization administration HCPCS code G9141 (includes the physician counseling the patient/family). This also applies to COVID-19 vaccine administration HCPCS codes and COVID-19 Non-Administration HCPCS codes.

Avoiding/Correcting This Error

Report influenza virus, pneumococcal pneumonia virus, and COVID-19 vaccines (and administration) with your charges on the 77X claim for informational and data collection purposes only. Report revenue code 0771 with the appropriate HCPCS/CPT code and actual charges on the claim line. The costs for these vaccines for are included in the FQHC’s cost report. Neither coinsurance nor deductible apply to either of these vaccines.

Hepatitis B vaccine is included in the PPS encounter rate. The charges of the vaccine and its administration can be included on a claim for a qualifying encounter. Report revenue code 0771 with the appropriate HCPCS/CPT code and actual charges on the claim line.

For any vaccination, an encounter cannot be billed if vaccine administration is the only service the FQHC provides.

Related Content

• COVID-19 Vaccine Policies & Guidance
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers, Section 70.4 - Vaccines

Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim.

Avoiding/Correcting This Error

Verify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable revenue codes will be displayed based on DOS.

Use the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim.

Either the HCPCS code is missing from the claim (or) is not on file for one of the following reason(s):

1. The HCPCS code entered on the claim is not a valid HCPCS/CPT code.
2. The HCPCS code entered on the claim is not billable to Medicare.

Verify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable HCPCS codes will be displayed based on DOS.

Avoiding/Correcting This Error

Use the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim.

Condition code ‘A6’ is required when one or more of the following HCPCS are present on the claim:

HCPCS Q0124 with from date less than 1/1/1995 or 90655–90660, 90724, 90732, G0008, G0009 or G9141

or

HCPCS G9017–G9020, G9033–G9036, and from date 12/1/2004 through 5/31/2005. HCPCS 90658 is termed effective 12/31/2010 and replaced by HCPCS Q2035–Q2039 effective 10/1/2010.

• Effective for dates of service 10/1/2010 and greater, HCPCS 90662 and 90670 are added to the list of codes.
• Effective for dates of service 5/9/2011 and greater, HCPCS 90654 was added to the list of codes.
• Effective for dates of service 7/1/2012 and greater, HCPCS Q2034 was added to the list of codes.
• Effective for dates of service 11/20/2012 and greater, HCPCS 90661 was added to the list of codes.
• Effective for dates of service 1/01/2013 and greater, HCPCS 90653, 90672, 90685–90688 and Q2033 was added to the list of codes.
• Effective for dates of service 1/1/2014 and greater, HCPCS 90673 was added to the list of codes.

Avoiding/Correcting This Error

Verify billing and correct where appropriate.

If reporting an influenza or pneumococcal vaccines along with a billable encounter, include the A6 condition code on the claim.

Related Content

• 2012-2013 Immunizers’ Question & Answer Guide to Medicare Part B, Medicaid and CHIP Coverage of Seasonal Influenza and Pneumococcal Vaccinations ‒ This CMS guide addresses immunizers’ commonly asked questions about the administration and billing of influenza and pneumococcal vaccines to Medicare, Medicaid and CHIP patients. It also includes questions and answers that are particularly relevant to the 2012‒2013 influenza immunization season.

FQHC PPS supplemental rate is not present for the MA-plan.

Avoiding/Correcting This Error

Submit an estimate of the average MA payments (per visit basis) for covered FQHC services to NGS (for the first two rate years). Submit a documented estimate of the average per visit payment for MA enrollees, for each MA plan you contract with, and any other information as may be required to enable NGS to accurately establish an interim supplemental payment.

Expected payments from the MA organization would only be used until actual MA revenue and visits collected on the FQHC’s cost report can be used to establish the amount of the supplemental payment.

Related Content

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers, Section 60.4 - Billing for Supplemental Payments to FQHCs under Contract with Medicare Advantage (MA) Plans
 

Hospice: Status is 01. Check discharge reason and OC.

Avoiding/Correcting This Error

Hospice – Clarify reason for discharge. Claim is being returned for one of the following reasons:

• Remarks are not present or do not indicate valid reason for discharge/transfer.
• Remarks indicate beneficiary is deceased, therefore patient status 01 (Discharged to home or self-care) is invalid.
• Invalid type of bill (812, 822, 813 or 823) used with patient status 01, should be 811, 821, 814 or 824).
• OC 42 date, thru date on claim and/or date entered in remarks are not the same.
• If the beneficiary moved out of service area with a transfer, patient status should be 50 or 51. Do not report OC 42.
• If the beneficiary revoked or discharged to a VA hospital, remarks must state "revoked or discharged to a VA hospital" and the applicable date. The date in remarks must be equal to the OC 42 date and thru date of claim.
• If the beneficiary moved out of service area (without a transfer) remarks must indicate beneficiary moved out of service area (without a transfer) and the applicable date. Condition Code (CC) 52 must be present. Do not report OC 42.
• If the beneficiary discharged for cause, remarks must indicate beneficiary discharged for cause with the appropriate date and CC H2 must be present on the claim. Do not report OC 42.
• OC 42 is present and remarks are not equal to "beneficiary revoked" or "discharged to a va hospital."

Hospice: Hospice claim received and the ‘From’ date falls within an established hospice election period and the start “2” date is equal to zeros (no change of ownership or provider change has occurred). The provider number on this claim is not equal to provider “1” on established hospice election period.

Avoiding/Correcting This Error

• If a transfer occurred, verify that all claims and notices are submitted in order. The transferring-from hospice agency needs to submit their final claim prior to the transferring-to hospice agency submitting their notice of change/transfer (TOB 8XC).
• If a change of ownership has occurred, verify that the notice of change of ownership (TOB 8XE) is submitted and finalized prior to submitting claims under the new provider number.
• Check HIQA to see how the elections are presently posted. Correct the appropriate NOEs or claims and then resubmit this claim.

Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code.

Avoiding/Correcting This Error

Hospice – This error occurs when a claim is submitted and the previous month's claim has not been found in the system or there is a gap between Through date of the previous claim and From date on this claim. Verify dates of service submitted on claim and ensure claims have been submitted in date order (no missing months).

Note that there is a workaround when submitting adjustments to claims where there is a transfer in the benefit period. Enter the "Start Date 1" in the current benefit period as the admission date on the claim rather than the admission date. This will allow all days in the period to be counted in the RHC payment calculation. When resubmitting enter remarks: "adjust due to RHC errors SE17014."

Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period.

Avoiding/Correcting This Error

When the hospice NOE was received it fell within a previously established election period.

• Verify that the NOE is billed with correct dates.
• If benefit period from the previous hospice is still open, allow that hospice to complete billing before updating the NOE.

Hospice: A hospice NOE with an admission date on or after 10/1/2014 must be received within five calendar days after the effective date of the hospice election. An initial hospice claim (where the from date matches the admit date) has been received where the NOE was not received timely and OSC 77 is either missing or contains invalid dates.

Avoiding/Correcting This Error

In instances where a NOE is not timely-filed, the days of hospice care from the hospice admission date to the date the NOE is submitted to and subsequently processed by the Medicare contractor will not be covered. The hospice shall report these noncovered days on the claim with an OSC 77, and charges related to the these days shall be reported as noncovered, or the claim will be returned to the provider. The noncovered days will be provider liable, and the beneficiary cannot be billed for them.

A hospice may request an exception to the timely filing NOE rules which, if approved, waives the consequences of filing a NOE late. Even if a hospice believes that exceptional circumstances beyond its control are the cause of its late-filed NOE, the hospice must still file the associated claim with the OSC 77 to identify the noncovered, provider liable days. The hospice will also report a KX modifier with the site of service code (Q HCPCS codes) associated with the earliest dated level of care line on the claim along with remarks to explain the reason for the late NOE.

Related Content

• Notice of Election: Timely Filing of Hospice Elections

Home Health: The From date on the HH NOA falls within an existing home health admission period.

Avoiding/Correcting This Error

Always verify billing before submitting a new NOA for a beneficiary admission.

There should not already be an NOA in the system pending processing or finalized prior to submitting a new NOA for a beneficiary. HHAs should not submit multiple NOAs for same admission.

Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code.

Avoiding/Correcting This Error

Hospice – This error occurs when a claim is submitted and the previous month's claim has not been found in the system or there is a gap between Through date of the previous claim and From date on this claim. Verify dates of service submitted on claim and ensure claims have been submitted in date order (no missing months).

Note that there is a workaround when submitting adjustments to claims where there is a transfer in the benefit period. Enter the "Start Date 1" in the current benefit period as the admission date on the claim rather than the admission date. This will allow all days in the period to be counted in the RHC payment calculation. When resubmitting enter remarks: "adjust due to RHC errors SE17014."

Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period.

Avoiding/Correcting This Error

When the hospice NOE was received it fell within a previously established election period.

• Verify that the NOE is billed with correct dates.
• If benefit period from the previous hospice is still open, allow that hospice to complete billing before updating the NOE.

Home Health: The From date on the HH NOA falls within an existing home health admission period.

Avoiding/Correcting This Error

Always verify billing before submitting a new NOA for a beneficiary admission.

There should not already be an NOA in the system pending processing or finalized prior to submitting a new NOA for a beneficiary. HHAs should not submit multiple NOAs for same admission.

The spelling of the beneficiary’s name or the beneficiary’s MBI on the claim differs from the information in the beneficiary’s master file.

Avoiding/Correcting This Error

The beneficiary’s name listed on the claim has to be an exact match to what is posted on CWF. Be sure that any special characters (including apostrophes, dashes, commas) and suffixes (Jr., Sr., III) that are included on the Medicare file are also reflected on the claim.

A beneficiary’s MBI may be updated if coverage changes. Be sure to include the updated MBI on the claim.

Use CWF or NGSConnex to verify the spelling of the beneficiary's name and/or identify a logically deleted MBI.

Correct claim to update beneficiary's name and/MBI and resubmit the RTP claim. was issued for Medicare contractors to return claims to provider when the name and MBI on the claim does not match what is on CWF.  

Related Content

• Change Request 7260 Revised: Common Working File Name and Health Insurance Claim Number Mismatch - provides instructions for using CWF to avoid this RTP
• Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process

Hospice revocation (8XB), change of provider (8XC), void of election period (8XD) or change of ownership (8XE) does not match to a posted election period on the hospice master record for this beneficiary.

Avoiding/Correcting This Error

When submitting a transaction to indicate the beneficiary’s election to revoke the hospice benefit, transfer the patient, cancel the election, or a change of ownership, the information on the transactional bill type must match a current, open election for the beneficiary.

Related Content

• CMS IOM, Publication 100-04, Processing Hospice Claims, Chapter 11, Section 20.1

Hospice NOE received for revocation (8XB) or void of election period (8XD) and the start date on the transaction falls within a previously established hospice election period on the hospice master record for this beneficiary.

Avoiding/Correcting This Error

Hospice – When submitting a hospice Notice of Termination/Revocation (TOB 8XB) or a Cancel Notice of Election (TOB 8XD) ensure that the From date on the transaction matches the Start date posted on CWF for that hospice election period.

Hospice: The hospice NOE or revocation (8xB) and start date matches a posted hospice election period start date current termination date and revocation indicator is other than zero. This is a duplicate revocation notice, or a claim has processed with occurrence code ‘23’ date of cancellation, or ‘42’ date of hospice revocation, which has caused the revocation information to be posted to the master record.

Avoiding/Correcting This Error

The 8xB (NOTR) transaction should only be submitted when the beneficiary revokes the hospice benefit or is discharged alive and there is no final claim in the system indicating termination of the hospice benefit. If the claim has already been filed with an occurrence code indicating the hospice benefit was terminated, the NOTR is not required.

Related Content

• Hospice Notice of Election Termination/Revocation

Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3, occurrence code 27 is reported on the claim for the billing period in which the certification or recertification was obtained. Therefore:

• If the certification/recertification was done prior to the service dates on the claim, an occurrence code 27 is not appropriate
  or
• When the claim dates of service are spanning a current election period, the occurrence code 27 date must equal the start date of the next election period. (Note that the occurrence code 27 date will create the next election period if one is not currently present.)
  or
• If billing an occurrence code 27 date for a late recertification, an occurrence span code 77 must also be present for the days that are prior to the late recertification date.

Avoiding/Correcting This Error

Ensure the usage of an appropriate certification or recertification date in accordance with occurrence code 27.

Related Content

• Avoiding Reason Code U5181: Appropriate Use of Occurrence Code 27/Occurrence Span Code 77 Job Aid
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11 (428 KB)

The dates of service are during both a hospice election period and a MA plan's period that is in a VBID model.

Avoiding/Correcting This Error

Hospice – This reason code is a notification to the provider of a VBID patient. For more information, including calendar-year specific downloadable lists of service area plan benefit packages (PBPs) and contact information, please refer to the CMS web page, Medicare Advantage Value-Based Insurance Design Model. Claims rejected with U523A will open benefit periods in Medicare’s eligibility systems. Hospice agencies must send all notices and claims to both the participating MAO and MAC on timely basis. You must send all notices and claims to both the participating MAO and your Medicare Administrative Contractor (MAC). The MAO will process payment, and the MAC will process the claims for informational and operational purposes and for CMS to monitor the Model. If you contract to provide hospice services with the plan, be sure to confirm billing and processing steps before the calendar year begins, as they may be different.

Please Note

• While agencies are encouraged to reach out to participating MAOs about contracting opportunities, you are not required to contract. If you choose not to contract, the participating MAO must continue to pay you at least equivalent to Original Medicare rates for Medicare-covered hospice care.
• The model does not permit prior authorization requirements around hospice elections or transitions between different levels of hospice care.

FQHC PPS TOB 77X is submitted and at least one of the specific payment codes G0466‒G0470 is not present.

Avoiding/Correcting This Error

• Effective with the implementation of Change Request 8743, when reporting an encounter/visit for payment, the claim (77X TOB) must contain a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds to the type of visit
• Verify the billing and correct where appropriate

This claim was submitted for FQHC PPS reimbursement and not reported with a payment code.

Avoiding/Correcting This Error

When submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Also be sure to report a qualifying visit HCPCS code line to indicate the services provided during the encounter, as well as any incident-to services.

FQHC PPS payment codes:

• G0466 – medical encounter, new patient
• G0467 – medical encounter, established patient
• G0468 – IPPE or AWV
• G0469 – mental health encounter, new patient
• G0470 – mental health encounter, established patient

Report with billable encounter revenue code:

• 052X (medical encounter)
• 0900 (mental health encounter)
• 0519 (supplemental MAO payment)

Each payment code (encounter) line must have a corresponding service line with a HCPCS code that describes the qualifying visit. Qualifying visit HCPCS codes are found on CMS’ FQHC center website.

Avoiding/Correcting This Error

Use the claim correction option to report the payment code and coordinating qualifying visit HCPCS code and resubmit the claim for processing.

Related Content

• FQHC PPS webpage

The claim lacks required device code or required procedure code.

Avoiding/Correcting This Error

• Verify billing and correct where appropriate.
• Review the Federally Qualified Health Centers (FQHC) section of the CMS website for the FQHC PPS-specific payment codes.

This claim was submitted for FQHC PPS reimbursement and not reported with a qualifying visit HCPCS code.

When submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Each payment code (encounter) line must have a corresponding service line with a HCPCS code that describes the qualifying visit. Qualifying visit HCPCS codes are found on CMS' FQHC center website.

Avoiding/Correcting This Error

Use the claim correction option to report the payment code and coordinating qualifying visit HCPCS code and resubmit the claim for processing.

Related Content

• Federally Qualified Health Centers (FQHC) Center website
• FQHC PPS webpage

FQHC PPS TOB 77X one of the specific payment codes G0466‒G0470 is present with a qualifying visit but revenue codes 0519, 052x or 0900 is not present.

Avoiding/Correcting This Error

Medicare payment is reflected only on claims lines with the revenue codes as follows:

• 0521 – Clinic visit by member to RHC/FQHC
• 0522 – Home visit by RHC/FQHC practitioner
• 0524 – Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF
• 0525 – Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility
• 0527 – RHC/FQHC visiting nurse service(s) to a member’s home when in a home health shortage area
• 0528 – Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)
• 0519 – Clinic, other clinic (only for the FQHC supplemental payment)
• 0900 – Mental Health Treatment/Services

Related Content

• Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 50 – General Requirements for RHC and FQHC Claims

FQHC PPS TOB 77X one of the specific payment codes G0466–G0470 is present with a qualifying visit but revenue code's 0519, 052X or 0900 is not present.

Avoiding/Correcting This Error

When submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Also be sure to report a qualifying visit HCPCS code line to indicate the services provided during the encounter:

FQHC PPS payment codes:

• G0466 – medical encounter, new patient
• G0467 – medical encounter, established patient
• G0468 – IPPE or AWV
• G0469 – mental health encounter, new patient
• G0470 – mental health encounter, established patient

Report with billable encounter revenue code:

• 052X (medical encounter)
• 0900 (mental health encounter)
• 0519 (supplemental MAO payment)

Avoiding/Correcting This Error

Use the claim correction option to report the payment code, coordinating qualifying visit HCPCS code, and billable encounter revenue code and resubmit the claim for processing.

The principal diagnosis code reported is considered supplementary or an additional code and cannot be used as the principal diagnoses. A supplementary or additional diagnosis code is not allowed as a principle diagnosis code.

Avoiding/Correcting This Error

Prevent future similar errors by checking the I/OCE and ICD-10 official guidelines prior to claim submission.

Verify the diagnosis codes reported; correct and resubmit.

Related Content

• The I/OCE Quarterly Release Files include information on diagnosis codes, including unacceptable principle diagnosis codes
  • I/OCE related Change Requests include updates to the codes allowed/not allowed as a principle diagnosis code. Example: Change Request 11944, October 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.3, effective 10/1/2020, includes a list of unacceptable principle diagnosis additions.
• The annual “ICD-10-CM Official Guidelines for Coding and Reporting” include guidelines on the selection of a principal diagnosis code.
  • For FY 2022 refer to FY 2022 ICD-10-CM Coding Guidelines - Updated 02/01/2022
     

The claim is bill type 13X or 85X and contains condition code 89 and a 9-digit ZIP Code; however, a one-to-one cannot be made to an OTP CCN.

Avoiding/Correcting This Error

Verify that all information is keyed correctly according to the applicable entry in the SAMHSA Opioid Treatment Program directory and your Medicare Part A enrollment information. When corrections are completed, return the claim for processing.

Related Content

• OTPs fully-certified by the SAMHSA and accredited by a SAMHSA-approved accrediting body can enroll in the Medicare Program to bill for covered services
• CMS website: Opioid Treatment Programs (OTP)
  • Includes: General information; Enrollment; Billing & Payment
• CMS MLN OPIOID Treatment Programs (OTPs) Medicare Enrollment Fact Sheet
   

Either the CPT or HCPCS code(s) reported on this claim was not been billed with a valid revenue code for the date(s) of service.

Avoiding/Correcting This Error

Verify HCPCS code using the FISS DDE Inquiries HCPCS file (option 14) to determine the allowable revenue codes based upon the date of service.

Verify billing and, if appropriate, correct the claim using the claims correction option to report the appropriate HCPCS/CPT code and resubmit the claim to your MAC.

Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim.

Avoiding/Correcting This Error

Verify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable revenue codes will be displayed based on DOS.

Use the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim.

This claim for a vaccine was returned for correction. Condition code 'A6' is required when billing the influenza and/or pneumococcal vaccine and/or COVID-19 vaccine and their related administration codes.

Avoiding/Correcting This Error

Append the “A6” condition code to the claim and F9 or resubmit.

Related Content

• Vaccines that are a Medicare covered benefit are included on the MLN Educational Tool Medicare Preventive Services
• For additional information on vaccines and pricing refer to the vaccine pricing section of CMS website Medicare Part B Drug Average Sales Price

Claims were submitted as Medicare primary and a positive working elderly record exists at CWF. The claim was submitted with an occurrence code 18, however the retirement date is the same as or prior to the effective date of the CWF MSPA record/s or is equal to the claim from date. The occurrence code 25 date benefits terminated by the primary payer is prior to dates of service and not equal to the occurrence code 18 (Retirement date). Or, occurrence code 25 is within or after the dates of service but there is an MSPA record which has the spouse as the policy holder.

Avoiding/Correcting This Error

Providers can currently check MSPA records thru HIQA, NGSConnex. If the records on CWF need updated this is handled by BCRC.

Verify the retirement date (occurrence code 18) and make changes if needed. If the retirement date is correct, add coding to indicate the date was verified and correct and resubmit the claim. Clarify if occurrence code 25 is for the record of the spouse and add claim coding and resubmit the claims.

The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date).

Avoiding/Correcting This Error

• If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, you may submit an adjustment (TOB XX7) to this claim to change it to an MSP claim.
• If the MSP record is incorrect because the beneficiary and/or spouse retired, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed) and code the beneficiary’s retirement date with OC 18 and/or the spouse’s retirement date with OC 19.
• If the MSP record is incorrect because of a reason other than retirement, contact the BCRC to request the record be updated. BCRC contact information:
  • Telephone: 855-798-2627 or TTY/TTD: 855-797-2627 (for hearing and speech impaired), available Monday-Friday, 8:00 a.m. – 8:00 p.m. ET (except holidays)
  • Address for general MSP correspondence: Medicare - MSP general correspondence, P.O. Box 138897, Oklahoma City, OK 73113-8897
  • Follow instructions in CMS article SE1416 (which may require you to fax the BCRC at Fax: 405-869-3307)
• Once the BCRC updates the MSP record, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed).
• Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates

Related Content

• Collect and Report Retirement Dates on Medicare Claims
• Correct a Beneficiary's MSP Record
• Correct or Adjust a Claim Due to an MSP-Related Issue
• Prevent an MSP Rejection on a Medicare Primary Claim
• MLN Matters® Article SE1416: Updating Beneficiary Information with the Benefits Coordination Recovery Center

The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date).  

Avoiding/Correcting This Error

• If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, you may submit an adjustment (TOB XX7) to this claim to change it to an MSP claim.
• If the MSP record is incorrect because the beneficiary and/or spouse retired, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed) and code the beneficiary’s retirement date with OC 18 and/or the spouse’s retirement date with OC 19.  

Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates.  

Related Content

• Collect and Report Retirement Dates on Medicare Claims
• Correct or Adjust a Claim Due to an MSP-Related Issue
• Prevent an MSP Rejection on a Medicare Primary Claim

The attending physician information on claim page 5 is not correct due to:

• The attending physician on claim page 5 is either invalid or not present in the PECOS Enrolled Physicians file, Type C records.
• Or, the attending physician NPI is present on the PECOS Enrolled Physicians file but the first four digits of the last name do not match.
• Or, The claim contains a through date of service equal to or greater than the terminations date on the PECOS Enrolled Physician inquiry screen

Avoiding/Correcting This Error

Verify billing and, if appropriate correct and return the claim. Online providers should press PF9 to restore the claim.

Related Content

• New Fiscal Intermediary Shared System Consistency Edit to Validate Attending Physician National Provider Identifier
• MLN® Matters article MM12889 “New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI”

Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS.

Avoiding/Correcting This Error

If you are billing for on-campus services only:

• Report the billing provider address only in the billing provider loop 2010AA
  • Do not report any service facility location in loop 2310E (or in DDE MAP 171F screen for DDE submitters)
• Refer to SE19007 for how to bill additional scenarios

Please verify billing and, if appropriate, correct by updating the practice address on the claim to exactly match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS.

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS.

Avoiding/Correcting This Error

If you are billing for on-campus services only:

• Report the billing provider address only in the billing provider loop 2010AA
  • Do not report any service facility location in loop 2310E (or in DDE MAP 171F screen for DDE submitters)
• Refer to SE19007 for how to bill additional scenarios

Please verify billing and, if appropriate, correct by updating the practice address on the claim to exactly match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS.

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The ER modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the ER modifier is not present on the claim.

Avoiding/Correcting This Error

The ER Modifier is used on all claim lines for all items and services furnished by a provider-based off-campus emergency department. The ER modifier is required to be reported for provider-based off-campus emergency departments that meet the definition of a “dedicated emergency department” as defined in 42 CFR 489.24 under the EMTALA regulations. Refer to CMS MLN Matters® articles MM11099 and MM11470 for additional information.

Please verify billing and, if appropriate correct by updating the ER modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The ER modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the ER modifier is not present on the claim.

Avoiding/Correcting This Error

The ER Modifier is used on all claim lines for all items and services furnished by a provider-based off-campus emergency department. The ER modifier is required to be reported for provider-based off-campus emergency departments that meet the definition of a “dedicated emergency department” as defined in 42 CFR 489.24 under the EMTALA regulations. Refer to CMS MLN Matters® articles MM11099 and MM11470 for additional information.

Please verify billing and, if appropriate correct by updating the ER modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim.

Avoiding/Correcting This Error

The PO modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus provider-based outpatient department (PBD). The PO modifier applies to a grandfather/excepted PBD. Grandfathered means that the facility became PD before 11/2/2015.

Please verify billing and, if appropriate correct by updating the PO modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim.

Avoiding/Correcting This Error

The PO modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus provider-based outpatient department (PBD). The PO modifier applies to a grandfather/excepted PBD. Grandfathered means that the facility became PD before 11/2/2015.

Please verify billing and, if appropriate correct by updating the PO modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim.

Avoiding/Correcting This Error

The PN modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus outpatient, PBD of a hospital. The PN modifier applies to a grandfather/excepted PBD for DOS on/after 1/1/2017. Non-grandfathered means that the off-campus practice location has an effective date on or after 11/2/2015.

Please verify billing and, if appropriate correct by updating the PN modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim.

Avoiding/Correcting This Error

The PN modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus outpatient, PBD of a hospital. The PN modifier applies to a grandfather/excepted PBD for DOS on/after 1/1/2017. Non-grandfathered means that the off-campus practice location has an effective date on or after 11/2/2015.

Please verify billing and, if appropriate correct by updating the PN modifier to the applicable claim line(s).

Online Providers: Press PF9 to store the claim.

Other Providers: Return to the MAC.

Related Content

• CMS Special Edition SE19007: Activation of Validation Edits for Providers with Multiple Service Locations
• URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
• Attention All OPPS Providers: Provider-Based Department
• Learn more about the Provider Practice Address Query screen (1D) in the FISS DDE
  • Instructions are included in our FISS DDE Provider Online Guide in Chapter IV: Inquiries Submenu (01) > Provider Practice Address Query (1D)

This claim (11X, 18X) rejected because it contains service dates that equal or overlap a previously denied claim.

Avoiding/Correcting This Error

Review the rejected and previously denied claims. Verify all information billed. If appropriate, make an adjustment or cancel to the previously processed denied claim or make corrections and submit a corrected adjustment claim.

Related Content

• NGS FISS DDE Provider Online Guide: How to Adjust a Claim

Whether any revenue code lines are equal or not, OPPS bill types (12X, 13X, 14X, 76X, 75X, 34X, or any bill containing condition code 07) cannot have overlapping dates when the provider numbers are equal, unless condition code G0 or 20 or 21 is present on the claim.

Avoiding/Correcting This Error

Check OPPS claims for potential overlapping dates of service prior to claim submission and bill accordingly

An adjustment bill must be submitted

• For bill type 34X, only vaccines and their administration, splints, casts, and antigens are paid under the OPPS
• For bill type 75X, only vaccines and their administration are paid under OPPS
• For bills containing condition code 07, only splints, casts and antigens will be paid under OPPS
• Send an adjustment claim to add any changes to first claims billed if no G0, 20 or 21 condition code is on the claim

This outpatient claim rejected as a duplicate to another outpatient claim for laboratory services.

Avoiding/Correcting This Error

Verify the from and through dates as well as the HCPCS codes and line-item DOS. If necessary, adjust the original claim to add all appropriate charges for all services rendered.

Related Content

• Refer to the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 16, Section 90.3 “Claims Processing Requirements for Panel and Profile Tests” for additional information.

Effective with admissions on and after 4/1/1995, all inpatient SNF and non-PPS bills must be processed in sequence. We have not received the claim immediately preceding the dates of service on this bill.

Avoiding/Correcting This Error

• Verify the admission date and from date on this claim
• Verify the patient’s MBI to make sure that it has been correctly reported
• If the MBI is incorrect, this edit will be assigned
• If admission and from dates as well as the MBI were correctly reported, you must submit the prior claim
• The prior claim must appear on your remittance advice before this claim can be processed
• Once the prior claim has shown on the remittance advice, you may return the claim to us

This claim reports DOS that are part of a continuing stay. We have not received the claim immediately preceding the DOS on this bill.

SNF inpatient claims have to be processed in sequence. That means that when the beneficiary is going to be in the SNF as an inpatient for several months in a row, claims for the months the beneficiary is in the SNF must be submitted one at a time, in sequential order. Subsequent claims in the stay should not be submitted until the prior month’s claim has processed and finalized.

Avoiding/Correcting This Error

Submit continuing-stay claims one month at a time and allow the claim to process before submitting the next month’s claim.

• Prior to submitting a continuing-stay claim, check the claim status using the FISS Inquiry Claim Summary option, the IVR, or the NGSConnex application to verify the prior month’s claim has finalized
• The prior claim must appear on your remittance advice before the next claim can be processed
• Once the prior claim has shown on the remittance advice, resubmit the RTP claim using claim correction options

This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:

• MBI number
• Type of bill (all three positions of any TOB)
• Provider number
• Statement from date of service
• Statement through date of service
• Total charges (0001 revenue line)
• Revenue code
• HCPCS and modifiers (if required by revenue code file)

Avoiding/Correcting This Error

Always verify the status of a submitted claim before submitting another claim. Verify claim status using the IVR system, FISS/DDE or the NGSConnex online portal. Per CMS mandate, PCC representatives are not permitted to provide claim status over the telephone. You can find the appropriate IVR telephone number on our website under Contact Us.

Even though Medicare payments are generally made 14 days after submission for electronic claims (29 days for paper claims), you should not use this as a guideline for resubmitting a claim.

If you submitted the duplicate claim in error and one of the claims paid, no additional action is required.

If you submitted the duplicate claim in error and both claims rejected, resubmit one of the claims.

If you submitted the duplicate claim to provide additional information for or to change the original claim, then adjust the original claim. If the original claim has not yet finalized, then wait for that claim to finalize (must appear on your remittance) and then submit the adjustment.

Reasons to adjust claims include, but are not limited to:

• Reporting services not previously submitted to Medicare
• Deleting services billed in error Correcting dates of service
• Adding/changing units of service Entering correct diagnosis codes
• Adding primary payer’s payment information (MSP)

Each line of charges on this claim has been rejected and/or rejected and denied

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field
2. Press <F1>/<PF1> to access the reason code file
3. Key the line item reason code over the claim level reason code and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

Related Content

• Reminder on Deleting Revenue Code Lines in the Fiscal Intermediary Standard System Direct Data Entry System

Each line of charges on this claim has been rejected and/or rejected and denied

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field
2. Press <F1>/<PF1> to access the reason code file
3. Key the line item reason code over the claim level reason code and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim

Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three.

Related Content

• Reminder on Deleting Revenue Code Lines in the Fiscal Intermediary Standard System Direct Data Entry System

All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability.

Avoiding/Correcting This Error

Review each line level denial reason code(s). Follow the steps provided in that line level reason code narrative. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field
2. Press <F1>/<PF1> to access the reason code file
3. Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim
5. Press <F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three

Important: Claims and claim line items that have been medically denied cannot be adjusted; providers must go through the appeals process to submit documentation to support any changes to denied line items.

Related Content

• Centers for Medicare & Medicaid Services Internet Only-Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60. (1.5 MB)

All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability.

Avoiding/Correcting This Error

Review each line level denial reason code(s). Follow the steps provided in that line level reason code narrative. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:

1. From Claim Page 02, press <F11>/<PF11> twice; the line level reason code will be shown in the Denial Reason field or the Line Item Reason Codes field
2. Press <F1>/<PF1> to access the reason code file
3. Key the line item reason code over the claim level reason code, and press <Enter> to view the line item reason code narrative
4. After reviewing the reason code narrative, press <F3>/<PF3> to return to the claim
5. Press <F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three

Important: Claims and claim line items that have been medically denied cannot be adjusted; providers must go through the appeals process to submit documentation to support any changes to denied line items.

Related Content

• Centers for Medicare & Medicaid Services Internet Only-Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60. (1.5 MB)

Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes.

Avoiding/Correcting This Error

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered.

Providers can visit the CMS Medicare Coverage Database (MCD) to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials.

Line level denial to indicate that none of the diagnosis codes on the claim support medical necessity of the services. Service was denied beneficiary liable, because the modifier “GA” is present on the line or occurrence code 32 is present on the claim and modifier “GA” is not present on any claim line.

Avoiding/Correcting This Error

Review coverage guidelines for the service being denied to ensure medical necessity of the services being provided to the beneficiary.

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. the diagnosis that are covered for the services provided.

Related Content

• NGSMedicare.com Medical Policy to review current Local Coverage Determinations (LCDs) and access a link to the National Coverage Policies (NCDs)
• CMS Beneficiary Notices Initiative (BNI)
• CMS Internet-Only Manual 100-04, Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections

All the line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an ABN.

Avoiding/Correcting This Error

You have the right to submit an appeal when you believe the medical records support that the denied services were reasonable and medically necessary.

Providers should review the information on the CMS website for Medically Unlikely Edits prior to claim submission. If the units rendered are in excess of the allowed units for that service, consider whether the excess units were actually rendered and billed correctly.

Related Content

• Medically Unlikely Edits and FAQs
• Appeals section
• Medicare Parts A & B Appeals Process

Line level reason code to indicate that none of the diagnosis codes on the claim support the medical necessity of the services. Service denied and the provider is liable.

Avoiding/Correcting This Error

Review coverage guidelines for the service being denied to ensure medical necessity of the services being provided to the beneficiary.

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided.

Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials.

Related Content

• Medicare Coverage Database
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual
• Appeals section
• Medicare Parts A & B Appeals Process

This claim/service was denied because the related or qualifying claim/service was not paid or identified on the claim.

Avoiding/Correcting This Error

Medicare does not cover medical and hospital services that are related to and required as a result of services that are not covered. Ensure that medical necessity requirements are met and well documented at the time of service. Submit all relevant medical records to Medical Review upon request.

Related Content

• CMS MLN Matters Publication Items and Services Not Covered Under Medicare

This claim/service was denied because the related or qualifying claim/service was not paid or identified on the claim.

Avoiding/Correcting This Error

Medicare does not cover medical and hospital services that are related to and required as a result of services that are not covered. Ensure that medical necessity requirements are met and well documented at the time of service. Submit all relevant medical records to Medical Review upon request.

Related Content

• CMS MLN Matters Publication Items and Services Not Covered Under Medicare

This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed).

Avoiding/Correcting This Error

Review coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity. 

When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:

• the dates of service being requested
• a list of documentation to submit

To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit

If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal.

Related Content

• Appeals section of our website

The documentation submitted supports that the services are not covered by Medicare. The beneficiary received a valid SNF ABN; thus, the beneficiary is liable for the noncovered charges on this claim.

Avoiding/Correcting this Error

The SNF should ensure that SNF services that are not covered are identified. After discussion with the beneficiary and/or representative you should properly issue an ABN and bill for the noncovered services accordingly.

Related Content

• CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 30 – Financial Liability Protections
  • Section 50 – Advance Beneficiary Notice of Non-coverage (ABN)
  • Section 70 – Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN)
• CMS Medicare FSS SNF ABN
• CMS MLN Matters article MM10567, Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN)
• CMS MLN Booklet, MLN006266, Medicare Advance Written Notices of Non-coverage

This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied.

Avoiding/Correcting This Error

Regularly access claims in status locations SB6001, SB6098, or SB6099 to obtain a listing of claims for which records have not yet been received by the MAC (Medical Review Department). Look for information on the Overview of EDI Products and Services page of our website to sign up to receive ADRs electronically.

Additional Information

This reason code can be prevented. When providers receive an ADR, the provider should respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all of the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Please note that, depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity.
 

This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied.

Avoiding/Correcting This Error

Regularly access claims in status locations SB6001, SB6098, or SB6099 to obtain a listing of claims for which records have not yet been received by the MAC (Medical Review Department). Look for information on the Overview of EDI Products and Services page of our website to sign up to receive ADRs electronically.

Additional Information

This reason code can be prevented. When providers receive an ADR, the provider should respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all of the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Please note that, depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity.
 

This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery.

Or

One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date.

Avoiding/Correcting This Error

Review reason code 59118 in the Direct Data Entry system for applicable codes. Alternatively, review the latest Change Requests/MLN^® Matters articles for relevant ICD-10 updates. The most current MLN Matters article is listed in ‘Related Content’ below and includes a link to the most current coding information.

File an appeal if applicable.

Related Content

• CMS National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA)
• CMS Internet-Only Manual 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.7
• CMS MLN Matters article MM13070, ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update, effective 7/1/2023
  • Note: MM13070 includes a link to a downloadable NCD spreadsheet on ICD-10 and additional coding relevant to select NCDs, including NCD 20.7

This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery.

Or

One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date.

Avoiding/Correcting This Error

Review reason code 59118 in the Direct Data Entry system for applicable codes. Alternatively, review the latest Change Requests/MLN^® Matters articles for relevant ICD-10 updates. The most current MLN Matters article is listed in ‘Related Content’ below and includes a link to the most current coding information.

File an appeal if applicable.

Related Content

• CMS National Coverage Determination (NCD) 20.7 Percutaneous Transluminal Angioplasty (PTA)
• CMS Internet-Only Manual 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.7
• CMS MLN Matters article MM13070, ICD-10 & Other Coding Revisions to National Coverage Determinations: July 2023 Update, effective 7/1/2023
  • Note: MM13070 includes a link to a downloadable NCD spreadsheet on ICD-10 and additional coding relevant to select NCDs, including NCD 20.7

As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals.

Avoiding/Correcting This Error

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. 5WEXC, based on coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment.

This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable.

Avoiding/Correcting This Error

If the beneficiary is entitled to Medicare Part B, an ancillary claim may be submitted to your MAC.

Related Content

• • Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Section 240, Chapter 4, Section 240 - Inpatient Part B Hospital Services

This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable.

Avoiding/Correcting This Error

If the beneficiary is entitled to Medicare Part B, an ancillary claim may be submitted to your MAC.

Related Content

• • Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Section 240, Chapter 4, Section 240 - Inpatient Part B Hospital Services

The MBI effective or end date is not within the dates of service submitted on the claim.

Avoiding/Correcting This Error

Check/verify the beneficiary's entitlement dates in the CWF. A Medicare beneficiary, or their authorized representative, may have requested a new MBI. Verify eligibility and MBI number, correct and return the claim.

The MBI effective or end date is not within the dates of service submitted on the claim.

Avoiding/Correcting This Error

Check/verify the beneficiary's entitlement dates in the CWF. A Medicare beneficiary, or their authorized representative, may have requested a new MBI. Verify eligibility and MBI number, correct and return the claim.

CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system or the FISS/DDE Provider Online System or NGSConnex to verify beneficiary eligibility prior to claim submission.

Related Content

• Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process

Inpatient services are reported on the claim and the beneficiary’s Part A coverage is not in effect; or outpatient services are reported on the claim and the beneficiary’s Part B coverage is not in effect. Therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS Provider Online System​​​​​, or NGSConnex to verify beneficiary eligibility prior to claim submission.

The claim rejected because services were provided prior to the beneficiary’s Medicare Part A or Part B entitlement date; therefore, no Medicare payment can be made.

Avoiding/Correcting This Error

Each beneficiary should be screened for eligibility. Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission.

Related Content

• CMS MLN Fact Sheet, MLN8816413, Checking Medicare Eligibility
• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide: Eligibility Lookup

The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period.

Avoiding/Correcting This Error

• Verify the admission date, from, and through dates on the claim and compare the dates to the MAO/HMO entitlement dates.
• Outpatient facilities and IPPS and IRF hospitals, or LTCH billing services within an MAO/HMO enrollment period must be submitted directly to the appropriate HMO contractor.
• Non-PPS inpatient hospital or inpatient SNF services which overlap either the effective or termination date of the MAO/HMO period will need to be split. Submit services rendered during the MAO/HMO enrollment period to the appropriate MAO/HMO contractor. Submit services rendered outside of the MAO/HMO enrollment period to the MAC.
• Verify HMO/MAO enrollment prior to claim submission by reviewing the CWF, the IVR system and FISS/DDE Provider Online System or NGSConnex.

The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period.

Avoiding/Correcting This Error

Verify the admission date, from, and through dates on the claim and compare the dates to the HMO entitlement dates.

• Outpatient facilities and inpatient noninpatient PPS and IRF hospitals, or LTCH billing services within an HMO enrollment period must be submitted directly to the appropriate HMO contractor.
• Non-PPS inpatient hospital or inpatient SNF services which overlap either the effective or termination date of the HMO period will need to be split. Submit services rendered during the HMO enrollment period to the appropriate HMO contractor. Submit services rendered outside of the HMO enrollment period to the MAC.
• IPPS, IRF, and LTCH claims and covered SNF services during the HMO enrollment period should be submitted to the MAC in order to post an informational no-pay encounter claim. It is necessary for these days to be captured by the CMS in the DSH (or LIP for IRF) calculations and to take benefit days from the spell of illness on the CWF.
• IPPS acute care teaching hospitals billing for IME payment must bill with both a condition code 04 and 69 and with covered charges.
• Effective with discharges on or after 10/1/2006, non-teaching IPPS hospitals, IRFs and LTCHs are required to submit informational no-pay encounter bills. These nonteaching hospitals are required to submit claim with covered charges and a condition code 04. Effective July 2012, IRF providers must use an appropriate HIPPS code based on the PAI assessment accompanied by an occurrence code 50 and the corresponding assessment date when submitting no-pay claims.
• Effective 1/1/2008, all SNF-covered services during an HMO enrollment period must be billed using condition code 04 with covered charges in order to post the no-pay encounter claim. No claim should be submitted to the MAC for noncovered SNF stays or for dates of service prior to 1/1/2008.

The claim was rejected because only services categorized as incidental or packaged services were billed. Incidental services include items such as routine supplies, anesthesia, recovery room use and most drugs.

Avoiding/Correcting This Error

Review the medical record to determine whether additional services should be reported. Correct/add any services that should/should not be included on the claim. Resubmit the corrected claim. 

Additional Information​​​​​

An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged. The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed and final rules each year. The status indicator for each HCPCS code is shown in OPPS Addendum B. The Addendum B files are also available on the CMS Addendum A and Addendum B Updates.

An example of services considered incidental are those services assigned to OPPS Status Indicator N. Status Indicator N denotes items/services that are packaged into the APC payment for other services and not separately reimbursed.

This outpatient claim was RTP for correction because the claim includes one or more services that are not billable to the MAC.

Avoiding/Correcting This Error

Verify Medicare coverage prior to billing and ensure that the correct codes are included on the claim.

If appropriate, correct and resubmit the claim.

Related Content

• CMS IOM, Publication 100-04, Medicare Claims Processing Manual
• CMS Booklet: Items and Services Not Covered Under Medicare

The service date(s) on this claim overlap a hospice election period and condition code 07 is not present.

Avoiding/Correcting This Error

If services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient).

Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system and FISS/DDE Provider Online System.

If appropriate, make corrections and resubmit a new claim.

Home Health: TOB is equal to home health NOA 32A and Admission Date, From Date and Through date do not match.

Avoiding/Correcting This Error:

When submitting the NOA, all date fields must match. Since the NOA is the start of the admission period, the "From" date, "Through" date and "Admission" date should all be the same.

This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed).

Avoiding/Correcting This Error

Review coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity.

When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:

• the dates of service being requested
• a list of documentation to submit

To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit

If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal.

Related Content

• Appeals section of our website

According to the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less.

Avoiding/Correcting This Error

Clinical progress notes should show evidence of a steady decline or downward trajectory in the beneficiary’s clinical status over time. Documentation should be objective, measurable and must support a life expectancy of six months or less. Beneficiaries who have improved or stabilized overtime and no longer have a reasonable expectation of a prognosis of six months or less should be discharged from the Medicare hospice benefit. There should be consistency between the certification documents and the hospice clinical progress notes.

Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim.

Avoiding/Correcting This Error

This reason code can and should be prevented. When providers receive an ADR, respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity. The ADR letter you received will indicate whether you have 30 days (Claim ADR) or 45 days (Medical Review ADR) to respond

TOB 77X with HCPCS G0109 is present on or after the parm date.

Prov Liability. NCD Rule 40.1

Avoiding/Correcting This Error

HCPC G0109 – Diabetes outpatient self-management training services, group (2 or more), per 30 minutes

Diabetes Counseling and Medical Nutrition Services

DSMT and MNT furnished by certified DSMT and MNT providers are billable visits in FQHCs when they are provided in a one-on-one, face-to-face encounter and all program requirements are met.

Related Content

Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 220.3

This claim is denied for payment because this inpatient 11X claim did not include covered diagnoses and procedure code(s) as required per National Coverage Decision (NCD) 20.4 specific to “Implantable Cardioverter Defibrillators (ICDs).

Avoiding/Correcting This Error

To prevent this error, ensure all Medicare coverage and medical necessity requirements are met prior to billing. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis and procedure codes that are covered for the services rendered.

If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered.

Review the coverage and billing relevant to NCD 20.4 prior to rendering the services. Refer to resources in the “Additional Information” section below.

Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials.

Related Content

• CMS Change Request 10865 National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
• MLN Matters®MM12104 Claims Processing Instructions for National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
• MLN Matters® Special Edition SE20006 NCD 20.4 Implantable Cardiac Defibrillators (ICDs)
• CMS Internet-Only Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.4 Implantable Cardioverter Defibrillators (ICDs)
• CMS ICD-10 website for Links related to ICD-10 NCDs
• NGS Appeals Information on the NGS web site and Medicare Parts A & B Appeals Process

As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals.

Avoiding/Correcting This Error

Ensure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. 5WEXC, based on coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services. A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment.

Unacceptable ICD-10 principle diagnosis code for dental services. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal.

Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a  malformed body member are not covered. 

Avoiding/Correcting This Error

Denial for dental services related to coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit.

Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare.

NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment.

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CMS MLN Matters Publication Items and Services Not Covered Under Medicare

Unacceptable ICD-10 principle diagnosis code. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal.

Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered.

Avoiding/Correcting This Error

NGS initiated edit 7WEXC, based on coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit.

Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare.

NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment.

Related Content

• CMS MLN Matters Publication Items and Services Not Covered Under Medicare

Home Health and Hospice: The claim From date is prior to the MBI effective date on the CWF crosswalk file and the MBI is the oldest occurrence in the crosswalk file.

Avoiding/Correcting This Error

HHH may only bill services provided to the patient after the effective date of their Medicare coverage. Verify the effective date(s) for the MBI of the beneficiary prior to billing. If a new MBI has been issued to the beneficiary, all claims must be submitted with the new MBI.

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Home Health: This claim was denied after review. The provider’s determination of noncoverage is correct.

Avoiding/Correcting This Error

This denial is based on review of a claim that was submitted as a demand bill. The charges on this claim are beneficiary liable. The beneficiary may be billed for these charges.

Home Health: The services on this claim fall within or overlap an MA HMO enrollment period.

Avoiding/Correcting This Error

Collect all insurance information from the beneficiary when admitted to your HHA. Talk to the beneficiary about insurance changes and check CWF before billing Medicare. Many times a claim will overlap an MAO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim.