Top Claim Errors
Reason Code Description Error Type Details
34984

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.

RTP
34984

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.

RTP
34977

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.

RTP
34977

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.

RTP
34985

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.

 

RTP
34985

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.

RTP
34986

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.

RTP
34986

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.

RTP
7C625

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

RTP
31194

Home Health: Statement From date on TOB 322 is on or after 01/01/2022. Please verify billing and if appropriate, correct.

RTP
37236

Home Health: 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.

If applicable submit reopen request to the Appeals department indicating error and the correction needed.
 

Denial
55H1L

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

Denial
55H1S

Hospice: Face-to-face encounter requirements not met.

Denial
55H2B

Home Health: Documentation submitted does not support homebound status.

Denial
55HTP

Home Health: The initial certification was missing/incomplete/invalid; therefore, the recertification episode is denied.

Denial
U5181

Hospice: 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.
RTP
31191

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

RTP
31197

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.

RTP
31836

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

RTP
32072

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.

Denial
32078

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, 85008899
    (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.

RTP
32078

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.
RTP
32243

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.

RTP
32266

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.

RTP
32402

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.

RTP
32402

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

RTP
32402

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

RTP
32404

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.
RTP
32405

The claim was returned for correction because the units billed are greater than 1 for an automated profile laboratory test per DOS. Hospitals and CAHs are required to bill all services rendered per DOS on the same claim, with few exceptions.

RTP
32415

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.
RTP
32415

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.

RTP
34072

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.

RTP
34293

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

Rejection
34295

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

Rejection
34538

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

Rejection
34538

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).  

Rejection
34538

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

Rejection
34538

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).  

Rejection
34538

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).  

Rejection
34540

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

Rejection
34540

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

Rejection
34963

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  

 

RTP
37098

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

RTP
37236

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.

Denial
38032

The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim.

Rejection
38032

The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim.

Rejection
38038

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.

RTP
38050

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)
Rejection
38092

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

Rejection
38119

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.

RTP
38119

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

RTP
38200

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)
Rejection
38312

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.

Rejection
38312

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

Rejection
39721

The requested nonmedical information was not received timely.

Rejection
39928

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

Denial
39928

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

Denial
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
52MUE

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.

Denial
52NCD

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.

Denial
52NCD

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.

Denial
53NCD

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.

Denial
53NCD

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.

Denial
54NCD

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.

Denial
55B31

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).

Denial
55B31

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).

Denial
55B31

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).

Denial
55H1L

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

Denial
55H1R

The NOE is invalid because it does not meet statutory/regulatory requirements.

Denial
55H1R

The NOE is invalid because it does not meet statutory/regulatory requirements.

Denial
55H1S

Face to face encounter requirements not met.

Denial
55H2B

Home Health: Documentation submitted does not support homebound status.             

Denial
55H3V

Home Health: Skilled nursing services were not medically necessary.

Denial
55S05

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.

Denial
55S29

There was insufficient documentation submitted to support the services billed.

Denial
56900

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.

Denial
56900

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.

Denial
56900

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.

Denial
56900

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.

Denial
59130

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

Prov Liability. NCD Rule 40.1

Denial
59301

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).

Denial
5ND07

The services are denied because the procedure and diagnosis coding requirements for bariatric surgery have not been met per National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity

Denial
5WEXC

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.

Denial
5WEXC

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.

Denial
7C387

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. 

Denial
7K073

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

Rejection
7K073

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

Rejection
7WEXC

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.

Denial
C7010

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

Rejection
C7010

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

Rejection
C7010

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

Rejection
CO-109

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

ANSI
CO-119

Benefit maximum for this time period or occurrence has been reached.

MA13:

Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

ANSI
CO-16

Remark Code N265

Missing/incomplete/invalid ordering provider primary identifier.

Remark Code N276

Missing/incomplete/invalid other payer referring provider identifier.

MOA Code MA13

Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

ANSI
CO-16

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

M79:
Missing/incomplete/invalid charge.

ANSI
CO-16

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

MA112:
Missing/incomplete/invalid group practice information.

ANSI
CO-16

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

MA112:
Missing/incomplete/invalid group practice information.

ANSI
CO-16

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

N382:
Missing/incomplete/invalid patient identifier.

ANSI
CO-16

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

N382:
Missing/incomplete/invalid patient identifier MBI.

ANSI
CO-16

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

N822:
Missing procedure modifiers(s).

ANSI
CO-16

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

N822:
Missing procedure modifiers(s).

ANSI
CO-22

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

ANSI
CO-22

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

ANSI
CO-B7

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

ANSI
U5065

Home Health: 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.

RTP
U5166

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.

RTP
37364

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.

Rejection
37402

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.

RTP
38031

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
Rejection
38032

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
Rejection
38037

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.

Rejection
38054

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.

Rejection
38055

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. 

Rejection
38200

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)
Rejection
39011

Home Health: This claim or adjustment has failed the timeliness of submission edit. Claims with dates of service on or prior to 12/31/2009 must have been received prior to 12/31/2010. Claims with dates of service 1/1/2010 and beyond must be submitted within one calendar year from the claim’s date of service.

For example if the claim DOS = 5/31/2017, then the claim must be received by 5/31/2018. The time limit for filing may be extended up to six months following notification to the provider or beneficiary of a Medicare Program administrative error. Claim remarks and date of notification are required to request the six month extension. Example: If untimely submission is due to a Medicaid retro buy-in to Medicare, that must be indicated in Remarks along with the date you were notified of the buy-in.

If it has been greater than one year from the date of the original determination or redetermination and the requested adjustment is based on the provider identification of clerical error, this must be submitted to the Appeals Department with a request for reopening form indicating the error made and the correction needed.

Medicare does not consider it “good cause” for reopening after the one year period when a third party payer mistakenly paid primary and now alleges that Medicare should have been primary.

Rejection
39929

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

Rejection
39934

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

Rejection
U5106

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

RTP
U5194

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.

RTP
U5200

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.

Rejection
U5211

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

Rejection
U5233

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

Rejection
U537F

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

RTP
U537K

Home Health: Home health cancellation (TOB 32D) does not match the home health admission period.

RTP
U5600

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.

Rejection
37364

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.

Rejection
37402

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.

RTP
38032

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
Rejection
38055

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. 

Rejection
38200

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)
Rejection
39929

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

Rejection
39934

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

Rejection
55H20

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

Denial
U5106

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

RTP
U5211

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

Rejection
U5233

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

Rejection
U537F

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

RTP
N5052

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.

RTP
OA-109

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

 

ANSI
OA-18

Exact duplicate claim/service.

ANSI
OA-18

Exact duplicate claim/service.

ANSI
PR-31

Patient cannot be identified as our insured.

ANSI
PR-204

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

 

ANSI
PR-31

Patient cannot be identified as our insured.

ANSI
PR-96

Non-covered charge(s).

N640:

Exceeds number/frequency approved/allowed within time period.

 

ANSI
U5065

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

RTP
U5065

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

RTP
U5111

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.

RTP
U5111

Hospice: The hospice NOE received for revocation (8XB) and start date matches a posted hospice election period start date, but the new revocation date matches current termination date and revocation indicator is other than occurrence code '23' date of cacellation, or '42' date of hospice revocation, which has caused the revocation information to be posted to the master record.

RTP
U5181

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.
RTP
U5200

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.

Rejection
U5200

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.

Rejection
U5200

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.

Rejection
U5210

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.

Rejection
U5210

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.

Rejection
U5210

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.

Rejection
U5220

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.

Rejection
U5233

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.

Rejection
U5233

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.

Rejection
U5233

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

Rejection
U5233

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.

Rejection
U523A

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

RTP
34293

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

Rejection
U538Q

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

Rejection
W7027

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.

Rejection
W7088

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

RTP
W7088

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

RTP
W7089

The claim lacks required device code or required procedure code.

RTP
W7089

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

RTP
W7090

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.

RTP
W7090

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.

RTP
W7113

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.

RTP
W7A01

Hospice: The OPPS version of OCE has detected an error in the first diagnosis code.

RTP