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

Avoiding/Correcting This Error

Verify that the initial certification is complete and includes all necessary elements, such as the patient’s homebound status, the need for skilled services, and a face-to-face encounter with a physician or allowed nonphysician practitioner. Ensure that the initial certification is obtained and signed by the physician before the start of home health services and keep it on file for future recertifications. Documentation should include a clear narrative justifying the medical necessity for home health services, and must be legible, containing the date, provider signature and all required content. The certification must be completed by a physician or NPP and the required face-to-face encounter must occur within 90 days prior to or 30 days after the start of home health care.

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.1.1, 30.1.2

Home health:  The ‘From’ and ‘Through’ dates on the HH claim fall outside a HH admission period.

Avoiding/Correcting This Error

All dates of service reported on a period of care claim must be on or after the date of admission. Verify the from and through dates billed and all line-item dates of service to ensure the dates are within the admission to home health care.

*Note: Some periods of care with dates of service three years past the admission date returned in error for U537I. A correction has been installed to fix this error. Providers should resubmit any claims that were incorrectly RTP'd for the U537I reason code

A claim has been submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk.

Verify the MBI submitted on the claim matches the MBI in the Common Working File. If a new MBI has been assigned, follow the guidelines regarding the claim submission:

• For dates of service before the MBI change date use old or new MBI
• If the new MBI was assigned in the middle of the billing period use old or new MBI
• For dates of service that are entirely on or after the effective date of the MBI change use new MBI

Related Content

• What do Medicare Beneficiary Identifiers (MBIs) mean for health care providers & office managers?
• Home Health Billing When a New MBI is Assigned

Patient status is equal to 30 on TOB 81X or 82X, excluding frequency code A–E or 8, with From date of service on or after 7/1/2013, and the statement To date is not equal to the last day of the billing period month.

Avoiding/Correcting This Error

Hospice claims are required to be billed monthly. Verify the month beginning and ending date and the ‘From’ and ‘To’ dates on your claim. The claim must span the entire month for continuing care claims.

Home Health: Documentation submitted does not support homebound status.             

Avoiding/Correcting This Error

Ensure the submitted documentation supports the beneficiary is confined to the home.

An individual shall be considered “confined to the home” (homebound) if the following two criteria are met:  

1. Criterion One: 
   
   The patient must either:
   Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence.
   
   OR
   
   Have a condition such that leaving his or her home is medically contraindicated. If the patient meets one of the criterion one conditions, then the patient must ALSO meet two additional requirements defined in criterion two below.  
    
2. Criterion Two:
   
   There must exist a normal inability to leave home;  
   
   AND
   
   Leaving home must require a considerable and taxing effort.

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.

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.

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.

Related Content

• Local Coverage Determination Hospice- Determining Terminal Status

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

• To avoid this error:
  • When submitting your Medicare primary claim, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
• To correct this error:
  • If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, submit an adjustment (TOB XX7) to this rejected claim to change it to an MSP claim (or a conditional claim, depending on the primary payer's response).
  • If the MSP record is incorrect and Medicare is primary, submit an adjustment (TOB XX7) to this rejected claim to change it to Medicare primary as you billed originally. However, on the adjustment, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
  • Note: Only if there is no claim coding available to report on the adjustment the reason Medicare is primary, you may ask the beneficiary or other party to contact the BCRC using the contact information below, to request that the MSP record be corrected. Providers do not contact the BCRC for this reason. Submit your adjustment claim once the MSP record in the CWF is corrected.
  • Do not resubmit claims rejected for 34538 as they will reject as duplicates. 
  • 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). 
    • Medicare-Data Collections, P.O. Box 138897, Oklahoma City, OK 73113-8897. 

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
• CMS MLN® Booklet: Medicare Secondary Payer

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

• To avoid this error:
  • When submitting your Medicare primary claim, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
• To correct this error:
  • If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, submit an adjustment (TOB XX7) to this rejected claim to change it to an MSP claim (or a conditional claim, depending on the primary payer's response).
  • If the MSP record is incorrect and Medicare is primary, submit an adjustment (TOB XX7) to this rejected claim to change it to Medicare primary as you billed originally. However, on the adjustment, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
  • Note: Only if there is no claim coding available to report on the adjustment the reason Medicare is primary, you may ask the beneficiary or other party to contact the BCRC using the contact information below, to request that the MSP record be corrected. Providers do not contact the BCRC for this reason. Submit your adjustment claim once the MSP record in the CWF is corrected.
  • Do not resubmit claims rejected for 34538 as they will reject as duplicates. 
  • 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). 
    • Medicare-Data Collections, P.O. Box 138897, Oklahoma City, OK 73113-8897. 

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
• CMS MLN® Booklet: Medicare Secondary Payer

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

• To avoid this error:
  • When submitting your Medicare primary claim, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
• To correct this error:
  • If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, submit an adjustment (TOB XX7) to this rejected claim to change it to an MSP claim (or a conditional claim, depending on the primary payer's response).
  • If the MSP record is incorrect and Medicare is primary, submit an adjustment (TOB XX7) to this rejected claim to change it to Medicare primary as you billed originally. However, on the adjustment, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
  • Note: Only if there is no claim coding available to report on the adjustment the reason Medicare is primary, you may ask the beneficiary or other party to contact the BCRC using the contact information below, to request that the MSP record be corrected. Providers do not contact the BCRC for this reason. Submit your adjustment claim once the MSP record in the CWF is corrected.
  • Do not resubmit claims rejected for 34538 as they will reject as duplicates. 
  • 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). 
    • Medicare-Data Collections, P.O. Box 138897, Oklahoma City, OK 73113-8897. 

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
• CMS MLN® Booklet: Medicare Secondary Payer

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) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer.

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

Remark Code N105: This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claims processing.

Avoiding/Correcting This Error

Palmetto GBA is the Medicare Administrative Contractor for processing claims of railroad retirees, regardless of their location. Providers and suppliers must verify patients' Medicare entitlement before submitting claims. Use the Eligibility function in NGSConnex for verification.

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

Remark Code M51 – Missing/incomplete/invalid procedure code

Avoiding/Correcting This Error

This denial message is specific to chiropractic claims with CPT/HCPCS codes that are not billable by Medicare enrolled chiropractors.

Medicare Part B coverage for chiropractic care is limited to spinal manipulations billed with CPT codes 98940, 98941, 98942 and 98943.

Please use this Chiropractic Services job aid to ensure claims are submitted accurately for reimbursement.  

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

Remark Code N382 - Missing/incomplete/invalid patient identifier.

Avoiding/Correcting This Error

The MBI is necessary for all claims submitted to MAC. Claims without a correct MBI are rejected, requiring providers to verify and resubmit them. To avoid this, use the Eligibility Lookup in NGSConnex before submitting claims for Medicare patients. If the MBI or identification card is unavailable, use the MBI Lookup Tool in NGSConnex with the patient’s name, date of birth, and Social Security Number, as NGS cannot release identification numbers to providers. If a verified MBI results in claim rejection, the patient should contact their local Social Security office to verify their Medicare benefits and enrollment.

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

Remark Code N822: Missing procedure modifier(s).

Avoiding/Correcting This Error

This rejection is the result of submitting a CPT/HCPCS code without a required modifier.

You are required to research the proper modifier to report with the CPT/HCPCS code then submit a new claim.

Please use these resources to identify and report the appropriate modifier:

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6
• Modifiers

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.

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 and the claim was billed with revenue code(s) other than 052X, 0900 or 0780
2. FQHC or RHC TOB 71X or 77X was billed without the LIDOS
3. TOB 71X or 77X claim was billed with revenue code(s) that are not billable in this setting 002X–024X, 029X, 045X, 054X, 056X, 060X, 065X, 067X–072X, 080X–088X, 093X–031X

Avoiding/Correcting This Error

Ensure the appropriate revenue code(s) and HCPCS/CPT code(s) are reported on the claim and each claim line contains the correct service date. Verify the information billed and PF9 to resubmit.

Related Content

• Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 9 – Rural Health Clinics/Federally Qualified Health Centers, Section 50 – General Requirements for RHC and FQHC Claims and Section 60 - Billing Requirements for RHCs and FQHCs
• MLN® Booklet: Federally Qualified Health Center 
• MLN® Booklet: Information for Rural Health Clinics

Line level error due to one or more revenue code lines billed with total charges that are either blank or zero.

Avoiding/Correcting This Error

Review the claim and either update the charges or remove the line containing zero or blank charges. Return the claim for processing. 

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(s) reported on this claim was not 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 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.

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

• Claim submitted with an organizational NPIs in place of individual attending physicians NPI
• Or, 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
• Or, the claim submitted with an NPI for a physician or non-physician practitioner specialties that is NOT eligible as an attending physician enrolled in PECOS in an approved status. Valid values are:
  • Doctor of medicine or osteopathy
  • Dental surgery (19)
  • Podiatric medicine (48)
  • Optometry (41)
  • Chiropractic medicine (35)
  • Physician assistant (97)
  • Certified clinical nurse specialist (89)
  • Nurse practitioner (50)
  • Clinical psychologist (68)
  • Certified nurse midwife (42)
  • Licensed clinical social worker (80)
  • Certified registered nurse anesthetist (43)
  • Registered dietitian/nutritional professional (71)
• Note: If the claim is for therapy services, then the physician or NPP who certified the patient's treatment plan, or POC, can be the attending physician

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® MM12889: “New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI”

The 77X claim was returned because the FQHC PPS supplemental payment rate was not included on the claim for the Medicare Advantage Plan.

Avoiding/Correcting This Error

Verify billing and, if appropriate, correct and return the claim.

Related Content

• Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
• CMS Internet-Only Manual 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

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)

FQHC claim contains a LIDOS that matches another LIDOS on a previously submitted claim for the same beneficiary, same PTAN, and same LIDOS.

Avoiding/Correcting This Error

If appropriate, correct and resubmit a new claim.  

To prevent this error on future claims: Ensure you have received all charges from all departments and that no claim has been submitted for the same DOS and beneficiary prior to submitting a claim.  Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

Related Content

• Interactive Voice Response (IVR) System
• NGSConnex User Guide
• FISS DDE Provider Online Guide

FQHC claim contains a LIDOS that matches another LIDOS on a previously submitted claim for the same beneficiary, same PTAN, and same LIDOS.

Avoiding/Correcting This Error

If appropriate, correct and resubmit a new claim.  

To prevent this error on future claims: Ensure you have received all charges from all departments and that no claim has been submitted for the same DOS and beneficiary prior to submitting a claim.  Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

Related Content

• Interactive Voice Response (IVR) System
• NGSConnex User Guide
• FISS DDE Provider Online Guide
   

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)

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

TOB 71X (RHC) contains HCPCS code G0108 or G0109 (diabetes self-management training) on a claim for DOS after the effective date. The provider is liable as per NCD 40.1. RHCs are not paid separately for DSMT and MNT services.

Avoiding/Correcting This Error

RHCs should not bill codes G0108 or G0109.

Related Content

• CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 70.5 - Diabetes Self-Management Training (DSMT) and Medical Nutrition Services (MNT)

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.

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.

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

Remark Code MA112:
Missing/incomplete/invalid group practice information.

Avoiding/Correcting This Error

The billing provider's information on the claim is missing or invalid. To avoid this error, ensure the following details are accurate and included: the billing provider's NPI, name, address, ZIP code and phone number.

Note: For group practices billing Medicare Part B, the NPI of the rendering physician or NPP is also required.

Claim/service 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 an 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 NGSConnex provider portal provides patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan.

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

Remark Code N265 – Missing/incomplete/invalid ordering provider primary identifier.

Remark Code N276 – Missing/incomplete/invalid other payer referring provider identifier.

Avoiding/Correcting This Error

Certain services require the name and NPI of the ordering or referring physician, depending on the service type. Definitions:

• Referring Physician: Requests an item or service for a Medicare beneficiary.
• Ordering Physician: Orders patient services like diagnostic tests, pharmaceutical services, or durable medical equipment.

All claims for services or items resulting from a physician’s order or referral must include the physician's name and NPI in Item 17 and 17b of the CMS-1500 claim form or electronic equivalent. This applies to:

• Medicare-covered services and items from a physician's order or referral
• Parenteral and enteral nutrition
• Immunosuppressive drugs
• Hepatitis B claims
• Diagnostic laboratory and radiology services
• Portable X-ray services
• Durable medical equipment
• Services where the ordering physician is the performing physician
• Services incident to those of a physician or NPP

Verify and correct the information in Item 17 and 17b of the CMS-1500 claim form before resubmitting the claim.

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

• From/Thru dates overlap
• Provider numbers are the same
• At least one revenue code is the same
• Duplicate diagnosis codes on both claims
• HCPC matches but different revenue codes
• Duplicate modifiers

Avoiding/Correcting This Error

If appropriate, correct and resubmit a new claim.

To prevent this error on future claims, ensure you have received all charges from all departments and that no claim has been submitted for the same DOS and beneficiary prior to submitting a claim.  Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

Related Content

• Interactive Voice Response (IVR) System

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

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 NGSConnex to obtain patient eligibility and benefit information.

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 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

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 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 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 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.

• 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, HETS and FISS DDE Provider Online System or NGSConnex.

Related Content

• Hospital Billing for Beneficiaries Enrolled in Option Code C Medicare Advantage Organization Plans 
• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide
• HIPAA Eligibility Transaction System (HETS)

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.

• 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, HETS and FISS DDE Provider Online System or NGSConnex.

Related Content

• Hospital Billing for Beneficiaries Enrolled in Option Code C Medicare Advantage Organization Plans 
• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide
• HIPAA Eligibility Transaction System (HETS)

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 claim contains a service that is not billable to the MAC.

Avoiding/Correcting This Error

Verify billing and, if appropriate, correct and resubmit the claim for payment.

Related Content

• Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services, Section 60 - Non RHC/FQHC Services 

FQHC PPS claim received a line level error due to no payment code billed.

Avoiding/Correcting This Error

Each FQHC PPS claim must be billed with a qualifying visit code, and associated line-item charges, along with all other FQHC services furnished during the encounter. A qualifying visit code is the code that qualifies the service for an encounter-based payment.  Payment codes include codes G0466‒G0470.

Related Content

• FQHC List of Qualifying Visit Codes
• Federally Qualified Health Centers (FQHC) Center
• CMS Internet-Only Manual 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers

FQHC PPS claim received a line level error due to no payment code billed.

Avoiding/Correcting This Error

Each FQHC PPS claim must be billed with a qualifying visit code, and associated line-item charges, along with all other FQHC services furnished during the encounter. A qualifying visit code is the code that qualifies the service for an encounter-based payment.  Payment codes include codes G0466‒G0470.

Related Content

• FQHC List of Qualifying Visit Codes
• Federally Qualified Health Centers (FQHC) Center
• CMS Internet-Only Manual 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers

FQHC PPS(77X TOB) claim contains one of the specific payment codes (G0466-G0470); however, a HCPCS code for the qualifying visit is not reported on the same day.

Avoiding/Correcting This Error

Payment for a FQHC encounter requires a medically necessary face-to-face visit. Each FQHC specific payment code (G0466-G0470) must have a corresponding service line with a HCPCS code that describes the qualifying visit. 

Verify billing. If appropriate, correct and resubmit the claim.

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.2 - Billing for FQHC Claims Paid under the PPS
• CMS list of qualifying visits for each payment specific code

FQHC PPS(77X TOB) claim contains one of the specific payment codes (G0466-G0470); however, a HCPCS code for the qualifying visit is not reported on the same day.

Avoiding/Correcting This Error

Payment for a FQHC encounter requires a medically necessary face-to-face visit. Each FQHC specific payment code (G0466-G0470) must have a corresponding service line with a HCPCS code that describes the qualifying visit. 

Verify billing. If appropriate, correct and resubmit the claim.

Related Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.2 - Billing for FQHC Claims Paid under the PPS
• CMS list of qualifying visits for each payment specific code

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
     

Claim line returned because the HCPCS code on the applicable revenue code line has a status code of M but the TOB is not 85X or the TOB is 85X, but the revenue code is not equal to 96X, 97X, or 98X.  The Medicare Physician Fee Schedule status indicator "M" describe services for physicians or professionals only.

Avoiding/Correcting This Error

Verify billing and, if appropriate, correct and resubmit the claim for payment.

Related Content

• CMS PFS Look-up Tool Overview

Claim line returned because the HCPCS code on the applicable revenue code line has a status code of M but the TOB is not 85X or the TOB is 85X, but the revenue code is not equal to 96X, 97X, or 98X.  The Medicare Physician Fee Schedule status indicator "M" describe services for physicians or professionals only.

Avoiding/Correcting This Error

Verify billing and, if appropriate, correct and resubmit the claim for payment.

Related Content

• MLN® Booklet: How to Use the PFS Look-up Tool

Line level error due to one or more revenue code lines billed with total charges that are either blank or zero.

Avoiding/Correcting This Error

Review the claim and either update the charges or remove the line containing zero or blank charges. Return the claim for processing. 

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.

Condition code “A6” (Pneumococcal pneumonia and influenza vaccines paid at 100%.) is not present, but is required, when billing the influenza or pneumococcal vaccine(s) and/or administration.

Avoiding/Correcting This Error

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

Related Content

• CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 10: Pneumococcal Pneumonia, Influenza Virus, Hepatitis B, and Coronavirus Disease (COVID-19) Vaccines and Administration
• CMS MLN® Educational Tool: Medicare Preventive Services

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

• Claim submitted with an organizational NPIs in place of individual attending physicians NPI
• Or, 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
• Or, the claim submitted with an NPI for a physician or non-physician practitioner specialties that is NOT eligible as an attending physician enrolled in PECOS in an approved status. Valid values are:
  • Doctor of medicine or osteopathy
  • Dental surgery (19)
  • Podiatric medicine (48)
  • Optometry (41)
  • Chiropractic medicine (35)
  • Physician assistant (97)
  • Certified clinical nurse specialist (89)
  • Nurse practitioner (50)
  • Clinical psychologist (68)
  • Certified nurse midwife (42)
  • Licensed clinical social worker (80)
  • Certified registered nurse anesthetist (43)
  • Registered dietitian/nutritional professional (71)
• Note: If the claim is for therapy services, then the physician or NPP who certified the patient's treatment plan, or POC, can be the attending physician

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”

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

• Claim submitted with an organizational NPIs in place of individual attending physicians NPI
• Or, 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
• Or, the claim submitted with an NPI for a physician or non-physician practitioner specialties that is NOT eligible as an attending physician enrolled in PECOS in an approved status. Valid values are:
  • Doctor of medicine or osteopathy
  • Dental surgery (19)
  • Podiatric medicine (48)
  • Optometry (41)
  • Chiropractic medicine (35)
  • Physician assistant (97)
  • Certified clinical nurse specialist (89)
  • Nurse practitioner (50)
  • Clinical psychologist (68)
  • Certified nurse midwife (42)
  • Licensed clinical social worker (80)
  • Certified registered nurse anesthetist (43)
  • Registered dietitian/nutritional professional (71)
• Note: If the claim is for therapy services, then the physician or NPP who certified the patient's treatment plan, or POC, can be the attending physician

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 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)

The 77X claim was returned because the FQHC PPS supplemental payment rate was not included on the claim for the Medicare Advantage Plan.

Avoiding/Correcting This Error

Verify billing and, if appropriate, correct and return the claim.

Related Content

• Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
• CMS Internet-Only Manual 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

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.

Avoiding/Correcting This Error

• If duplicate claim was submitted in error, no additional provider action is necessary. If it is determined that the claim was due to additional charges for a patient for a specific date of service, wait for the original claim to finalize and adjust (TOB XX7) the originally-processed claim.
• Prior to submitting a claim, ensure you have received the charges from all departments so you can submit one claim with all of the services rendered. Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

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.

Avoiding/Correcting This Error

• If duplicate claim was submitted in error, no additional provider action is necessary. If it is determined that the claim was due to additional charges for a patient for a specific date of service, wait for the original claim to finalize and adjust (TOB XX7) the originally processed claim.
• Prior to submitting a claim, ensure you have received the charges from all departments so you can submit one claim with all of the services rendered. Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

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

Regardless of whether any revenue code lines are equal or not, outpatient TOB 13X, 14X, 83X, or 85X cannot have overlapping DOS when the PTANS are equal. There are a few exceptions such as when:

1. One of the claims is for a pap smear only
2. One of the claims is for mammography screening only
3. The outpatient claim contains OSC 74 and the other claim has a DOS within the OSC 74 dates
4. The 14X and 83X are from a Maryland Waiver Provider (MWI=Y) and the 14X contains lab only and the 83X does not contain labs
5. One of the claims is for repetitive Part B services only for CAH (85X) TOB

Avoiding/Correcting This Error

Verify billing and if appropriate, correct and resubmit the claim.  

To prevent this error on future claims: Ensure that the correct bill type is submitted once you have received all charges from all departments and that no claim has been submitted for the same DOS and beneficiary, as applicable, prior to submitting a claim for payment.  Ensure that the correct TOB is used. Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

Related Content

• Interactive Voice Response (IVR) System
• NGSConnex User Guide
• FISS DDE Provider Online Guide
   

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)

FQHC claim contains a LIDOS that matches another LIDOS on a previously submitted claim for the same beneficiary, same PTAN, and same LIDOS.

Avoiding/Correcting This Error

If appropriate, correct and resubmit a new claim.  

To prevent this error on future claims: Ensure you have received all charges from all departments and that no claim has been submitted for the same DOS and beneficiary prior to submitting a claim.  Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

Related Content

• Interactive Voice Response (IVR) System
• NGSConnex User Guide
• FISS DDE Provider Online Guide
   

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, 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)

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
• Original Medicare (Fee-for-service) Appeals | CMS

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 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 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 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

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

The claim was denied due to missing documentation required to support the services billed. The documentation lacked evidence that all benefit category requirements were met and necessary criteria.

Avoiding/Correcting This Error

Respond promptly to a MAC, CERT, RAC, SMRC, or UPIC request for additional documentation.  Documentation is necessary to verify compliance with a benefit category requirement. Ensure that all records, including any treatment notes, certifications, etc. are submitted promptly to support that all billed services were rendered, meet reasonable and necessary criteria, and any additional coverage requirements.

Related Content

• CMS Internet-Only Manual 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 - No Response or Insufficient Response to Additional Documentation Requests, Item C -Insufficient Response
• Social Security Act Section 1815
• 42 Code of Federal Regulations Part 424.5(a)(6)

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.
 

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.

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.
 

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.

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

This inpatient (11X) claim contains one or more procedure codes indicating an implantable cardioverter defibrillator was inserted; however, one or more diagnosis codes required for coverage are missing. Therefore, the provider is liable. 

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.

To prevent similar denials, ensure that all coverage guidelines are documented and met prior to billing.

Related Content

• National Coverage Determination (NCD) 20.4 Implantable Cardiac Defibrillators (ICDs)
• Centers for Medicare and Medicaid Services Internet-Only Manual 100-03, Medicare NCD Manual, Chapter 1, Part 1, Section 20.4 ICDs
• Change Request 13390 contains a downloadable spreadsheet (zip file) with ICD-10-PCS and ICD-10-CM coding applicable to NCD 20.4

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

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.
• Review the coverage and billing relevant to NCD 100.1 prior to rendering the services. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. 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 Internet-Only Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 100.1 “Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity”
• See also the CMS ICD-10 website for Links related to ICD-10 NCDs
• NGS Appeals Information on the NGS website 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 (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.

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.

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 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, HETS and FISS/DDE Provider Online System.

If appropriate, make corrections and resubmit a new claim.

Related Content

• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide
• HIPAA Eligibility Transaction System (HETS)

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.

Related Content

• Home Health Billing When a New MBI is Assigned

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

HH+H 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.

Related Content

• Home Health Billing When a New MBI is Assigned

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.

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 FISS/DDE Provider Online System, HETS 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
• HIPAA Eligibility Transaction System (HETS)

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 FISS Provider Online System, HETS 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
• HIPAA Eligibility Transaction System (HETS)

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 FISS Provider Online System, HETS 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
• HIPAA Eligibility Transaction System (HETS)

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, HETS and FISS/DDE Provider Online System or NGSConnex.

Related Content

• Hospital Billing for Beneficiaries Enrolled in Option Code C Medicare Advantage Organization Plans 
• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide
• HIPAA Eligibility Transaction System (HETS)

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.

FQHC PPS claim received a line level error due to no payment code billed.

Avoiding/Correcting This Error

Each FQHC PPS claim must be billed with a qualifying visit code, and associated line-item charges, along with all other FQHC services furnished during the encounter. A qualifying visit code is the code that qualifies the service for an encounter-based payment.  Payment codes include codes G0466‒G0470.

Related Content

• FQHC List of Qualifying Visit Codes
• Federally Qualified Health Centers (FQHC) Center
• CMS Internet-Only Manual 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/Federally Qualified Health Centers

Claim not covered by this payer/contractor.  You must send the claim/service 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 NGSConnex provider portal provides patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan.

CO-109 Claim/service not covered by this payer/contractor.  You must send the claim/service to the correct payer/contractor.  

Remark Code N105 - This is a misdirected claim/service for an RRB beneficiary. Submit paper claims to the RRB carrier: Palmetto GBA, P.O. Box 10066, Augusta, GA 30999. Call 888-355-9165 for RRB EDI information for electronic claims processing.

Avoiding/Correcting This Error

Palmetto GBA is the Medicare Administrative Contractor for processing claims of railroad retirees, regardless of their location. Providers and suppliers must verify patients' Medicare entitlement before submitting claims. Use the Eligibility function in NGSConnex for verification.

CO-16 Claim/service lacks information or has submission/billing error(s)

Remark Code M51 - Missing/incomplete/invalid procedure code.

Avoiding/Correcting This Error

This denial message is specific to chiropractic claims with CPT/HCPCS codes that are not billable by Medicare enrolled chiropractors.

Medicare Part B coverage for chiropractic care is limited to spinal manipulations billed with CPT codes 98940, 98941, 98942 and 98943.

Please use this Chiropractic Services job aid to ensure claims are submitted accurately for reimbursement.

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

Remark Code MA112 - Missing/incomplete/invalid group practice information.

Avoiding/Correcting This Error

The billing provider's information on the claim is missing or invalid. To avoid this error, ensure the following details are accurate and included: the billing provider's NPI, name, address, ZIP code, and phone number.

Note: For group practices billing Medicare Part B, the NPI of the rendering physician or NPP is also required.

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

Remark Code N265 - Missing/incomplete/invalid ordering provider primary identifier.

Remark Code N276 - Missing/incomplete/invalid other payer referring provider identifier.

Avoiding/Correcting This Error

Certain services require the name and NPI of the ordering or referring physician, depending on the service type. Definitions: 

• Referring physician: Requests an item or service for a Medicare beneficiary.
• Ordering physician: Orders patient services like diagnostic tests, pharmaceutical services or durable medical equipment.

All claims for services or items resulting from a physician’s order or referral must include the physician's name and NPI in Item 17 and 17b of the CMS-1500 claim form or electronic equivalent. This applies to:

• Medicare-covered services and items from a physician’s order or referral
• Parenteral and enteral nutrition
• Immunosuppressive drugs
• Hepatitis B claims
• Diagnostic laboratory and radiology services
• Portable X-ray services
• Durable medical equipment
• Services where the ordering physician is the performing physician
• Services incident to those of a physician or NPP

Verify and correct the information in Item 17 and 17b of the CMS-1500 claim form before submitting the claim.

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

Remark Code N382 - Missing/incomplete/invalid patient identifier.    

Avoiding/Correcting This Error

The MBI is necessary for all claims submitted to MAC. Claims without a correct MBI are rejected, requiring providers to verify and resubmit them. To avoid this, use the Eligibility Lookup in NGSConnex before submitting claims for Medicare patients. If the MBI or identification card is unavailable, use the MBI Lookup Tool in NGSConnex with the patient’s name, date of birth, and Social Security Number, as NGS cannot release identification numbers to providers. If a verified MBI results in claim rejection, the patient should contact their local Social Security office to verify their Medicare benefits and enrollment.

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

Remark Code N822 - Missing procedure modifier(s).  

Avoiding/Correcting This Error

This rejection is the result of submitting a CPT/HCPCS code without a required modifier.

You are required to research the proper modifier to report with the CPT/HCPCS code then submit a new claim.

Please use these resources to identify and report the appropriate modifier:

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6
• Modifiers

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 NGSConnex to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer.

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.

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 NGSConnex to obtain patient eligibility and benefit information.

Hospice: The hospice claim denied because the physician listed as the attending physician does not have an active Medicare enrollment or is not opted-out to certify hospice claims.

Avoiding/Correcting This Error

This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date.

An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Refer to the following article for detailed instructions: 17729 and 17730 Hospice Claim Edits for Certifying Physicians.

Hospice: The hospice claim denied because the physician listed as the attending physician does not have an active Medicare enrollment or is not opted-out to certify hospice claims.

Avoiding/Correcting This Error

This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Attending field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date.

An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Refer to the following article for detailed instructions: 17729 and 17730 Hospice Claim Edits for Certifying Physicians.

Hospice: This claim denied because there is a termination date of the PECOS enrolled physician inquiry screen for the referring physician.

Avoiding/Correcting This Error

This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date.

An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Refer to the following article for detailed instructions: 17729 and 17730 Hospice Claim Edits for Certifying Physicians.

Hospice: This claim denied because there is a termination date of the PECOS enrolled physician inquiry screen for the referring physician.

Avoiding/Correcting This Error

This edit is applied if the NPI and first four letters of the physician’s last name submitted on the claim in the Referring field do not match the physician’s NPI and first four letters of the physician’s last name on the PECOS file, or physician’s does not have an active enrollment on the reported Occurrence Code 27 date.

An adjustment should be submitted when an input error (i.e., incorrect NPI, incorrect name spelling) is being corrected or the physician’s PECOS record has been updated. Refer to the following article for detailed instructions: 17729 and 17730 Hospice Claim Edits for Certifying Physicians.

Hospice: Claim was submitted with modifier ‘GY’ on a revenue line with covered charges.

Avoiding/Correcting This Error

Hospice room and board denials should be submitted as non-covered charges with revenue code 0659, HCPCS A9270, and the ‘GY’ modifier. Review the information submitted on your claim, correct, and resubmit.

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.

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.

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.

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

Avoiding/Correcting This Error

Review coverage and billing guidelines for the NOE to ensure that your NOEs are accurately billed.

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.2.1.1, Filing an Electronic Notice of Election

Hospice: The documentation submitted does not support a valid face-to-face encounter occurred.

Avoiding/Correcting This Error

Include all face-to-face encounter attestations for the third benefit period and after with your medical record submission to the ADR. Ensure that the CMS requirements for the face-to-face encounter have been met in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1. Failure to meet these requirements results in a failure by the hospice to meet the recertification obligation. The beneficiary would cease to be eligible for the benefit. Remember to verify the benefit period that the beneficiary is in with every admission, as the beneficiary may have received hospice services in the past.

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

Avoiding/Correcting This Error

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 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 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.

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.

Claim has occurrence code 77 with ‘From’ and ‘Through’ dates indicating non-coverage during this time. However, a line item date is present that is equal to or within this non-covered time and the charges are greater than zero.
Verify that the following was entered correctly: 

• Occurrence code and span dates
• Line item dates
• Charges

Avoiding/Correcting This Error

The occurrence span code 77 should only be used to indicate the span of days that were not covered on claims.

Related Content

• Appropriate Use of Occurrence Code 27 and Occurrence Span Code 77

Hospice: 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

• To avoid this error:
  • When submitting your Medicare primary claim, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
• To correct this error:
  • If the MSP record is correct, submit the claim to the primary EGHP. Once you receive payment, submit an adjustment (TOB XX7) to this rejected claim to change it to an MSP claim (or a conditional claim, depending on the primary payer's response).
  • If the MSP record is incorrect and Medicare is primary, submit an adjustment (TOB XX7) to this rejected claim to change it to Medicare primary as you billed originally. However, on the adjustment, report the reason Medicare is primary using claim coding in Prevent an MSP Rejection on a Medicare Primary Claim.
  • Note: Only if there is no claim coding available to report on the adjustment the reason Medicare is primary, you may ask the beneficiary or other party to contact the BCRC using the contact information below, to request that the MSP record be corrected. Providers do not contact the BCRC for this reason. Submit your adjustment claim once the MSP record in the CWF is corrected.
  • Do not resubmit claims rejected for 34538 as they will reject as duplicates.
  • 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).
    • Medicare-Data Collections, P.O. Box 138897, Oklahoma City, OK 73113-8897.

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
• CMS MLN® Booklet: Medicare Secondary Payer

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.

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.

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: 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: 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.

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: 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

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 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 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.