Reason Code | Description | Error Type | Details |
---|---|---|---|
CO-16 | Claim/service lacks information or has submission/billing error(s). MA112: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). MA112: Avoiding/Correcting This ErrorThe group practice information is either missing from this claim or invalid group information has been entered. Verify the following information, on the claim, from the CMS-1500 Claim Form Completion Instructions/ Medicare Part B CMS-1500 Crosswalk for 5010 Electronic Claims in order to ensure they are properly completed:
Reviewed: Apr 18, 2023 |
CO-16 | Claim/service lacks information or has submission/billing error(s). MA112: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). MA112: Avoiding/Correcting This ErrorThe group practice information is either missing from this claim or invalid group information has been entered. Verify the following information, on the claim, from the CMS-1500 Claim Form Completion Instructions/ Medicare Part B CMS-1500 Crosswalk for 5010 Electronic Claims in order to ensure they are properly completed:
Reviewed: Apr 18, 2023 |
CO-16 | Claim/service lacks information or has submission/billing error(s). N382: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). N382: Avoiding/Correcting This ErrorIn 2020, CMS removed the SSN-based identifier from the Medicare card to protect beneficiaries and offer better identity protection. The MBI is the patient identification number assigned to Medicare beneficiaries. Claims submitted to Medicare contractors must contain the MBI. Visit CMS’ MBI web page for detailed information
Make the appropriate correction to the claim and resubmit. Note: If you have entered the MBI exactly how it appears on the Medicare ID card and the patient advises that it’s the most recent copy they have, then the patient would need to contact Social Security to verify/obtain the correct information. Reviewed: Apr 18, 2023 |
CO-16 | Claim/service lacks information or has submission/billing error(s). N822: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). N822: Avoiding/Correcting This ErrorWe were unable to process this claim do it missing a required modifier for the CPT submitted. Please review a full listing of Modifiers Used in CMS-1500 Claim Reporting and append the appropriate modifier and resubmit the claim. Note: Since, this is considered a rejection you will not have the option to reopen the claim. Reviewed: Apr 18, 2023 |
CO-16 | Claim/service lacks information or has submission/billing error(s). N822: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). N822: Avoiding/Correcting This ErrorWe were unable to process this claim do it missing a required modifier for the CPT submitted. Please review a full listing of Modifiers Used in CMS-1500 Claim Reporting and append the appropriate modifier and resubmit the claim. Note: Since, this is considered a rejection you will not have the option to reopen the claim. Reviewed: Apr 18, 2023 |
CO-383 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. |
ANSI |
Claim Error Reason Code CO-383Error Description
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. Avoiding/Correcting This ErrorNational Government Services is the Part A and B MAC for Jurisdiction K and Jurisdiction 6 states. Please use the link below to determine where your claim should be sent. Reviewed: Apr 18, 2023 |
CO-383 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. |
ANSI |
Claim Error Reason Code CO-383Error Description
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at www.cms.gov. Avoiding/Correcting This ErrorNational Government Services is the Part A and B MAC for Jurisdiction K and Jurisdiction 6 states. Please use the link below to determine where your claim should be sent. Reviewed: Apr 18, 2023 |
CO/PR-29 | The time limit for filing has expired. |
ANSI |
Claim Error Reason Code CO/PR-29Error Description
The time limit for filing has expired. Avoiding/Correcting This ErrorProviders must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service. The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year if the provider can show good cause for the delay. Reviewed: Apr 18, 2023 |
CO/PR-29 | The time limit for filing has expired. |
ANSI |
Claim Error Reason Code CO/PR-29Error Description
The time limit for filing has expired. Avoiding/Correcting This ErrorProviders must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service. The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year if the provider can show good cause for the delay. Reviewed: Apr 18, 2023 |
OA-109 | Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor.
|
ANSI |
Claim Error Reason Code OA-109Error Description
Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor.
Avoiding/Correcting This ErrorMany times Medicare beneficiaries are enrolled in an MA plan, instead of “traditional fee-for-service” Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans,” are health plans offered by private companies approved by Medicare. Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan. During patient registration, it is also important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. This information helps determine who to bill and how to file claims with Medicare. During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by another contractor. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information. Reviewed: Apr 19, 2023 |
OA-18 | Exact duplicate claim/service. |
ANSI |
Claim Error Reason Code OA-18Error Description
Exact duplicate claim/service. Avoiding/Correcting This ErrorA 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:
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:
Remittance Advice Tips:
Reviewed: Apr 18, 2023 |
PR-31 | Patient cannot be identified as our insured. |
ANSI |
Claim Error Reason Code PR-31Error Description
Patient cannot be identified as our insured. Avoiding/Correcting This ErrorServices were denied for one or more of the following reasons:
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:
Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information. Reviewed: Apr 18, 2023 |
U5200 | CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
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 ErrorVerify that the MBI on the claim is for the correct beneficiary.
Reviewed: Apr 17, 2023 |
32402 | Either the CPT or HCPCS code(s) reported on this claim was not been billed with a valid revenue code for the date(s) of service. |
RTP |
Claim Error Reason Code 32402Error Description
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 ErrorVerify 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. Reviewed: Apr 17, 2023 |
12302 | The sum of covered and noncovered days must equal the total number of days in the statement covers period. |
RTP |
Claim Error Reason Code 12302Error Description
The sum of covered and noncovered days must equal the total number of days in the statement covers period. Avoiding/Correcting This ErrorVerify patient status. If a status 30 is used, you must count the through date in your calculation. If a same-day transfer, the ADMISSION, FROM and THROUGH date is the same, patient status of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, 71, 72, 82, 83, 85, 89, 90, 91, 93 or 94 is present with condition code 40, the claim must show one non-covered day. If not a same day transfer, but the FROM and THROUGH dates are the same, the claim must show one covered day. If the patient was transferred to a PPS hospital, the patient status reported must be '02'. Reviewed: Apr 17, 2023 |
19301 | If the operating physician’s information is required or present on the claim containing covered charges then the physician’s last name, first name, and valid NPI must also be present on the claim. |
RTP |
Claim Error Reason Code 19301Error Description
If the operating physician’s information is required or present on the claim containing covered charges then the physician’s last name, first name, and valid NPI must also be present on the claim. Avoiding/Correcting This ErrorAdd the missing information to the claim and F9 or resubmit. Reviewed: Apr 17, 2023 |
19508 | An invalid ICD-9 or ICD-10 diagnosis code is submitted on the claim. |
RTP |
Claim Error Reason Code 19508Error Description
An invalid ICD-9 or ICD-10 diagnosis code is submitted on the claim. Avoiding/Correcting This ErrorVerify your date(s) of service. Claims with through dates on or after 10/1/2015 must be billed with ICD-10 codes. Claims with through dates on or before 9/30/2015 must be billed with ICD-9 codes. Reviewed: Apr 17, 2023 |
30720 | Treatment Authorization Code must be entered on the lines one and two. If a third party is also involved, the Treatment Authorization Code must be entered on the first, second and third lines. |
RTP |
Claim Error Reason Code 30720Error Description
Treatment Authorization Code must be entered on the lines one and two. If a third party is also involved, the Treatment Authorization Code must be entered on the first, second and third lines. Avoiding/Correcting This ErrorCheck the alpha O’s and zeroes in your Treatment Authorization Code (taken from your OASIS matching key) and be sure to enter in all appropriate fields (if an MSP claim). The valid format for the Treatment Authorization Code is eighteen alpha/numerics:
If there is MSP involvement on this claim and Medicare is secondary, the Treatment Authorization Code must be entered on the lines one and two. If there is a third party also involved, the Treatment Authorization Code must be entered on the first, second and third lines. Reviewed: Apr 17, 2023 |
30727 | Effective 1/1/2015, all hospice claims (TOB 81X/82X) will be returned to the provider if the principal diagnosis on the claim is equal to a manifestation diagnosis code. |
RTP |
Claim Error Reason Code 30727Error Description
Effective 1/1/2015, all hospice claims (TOB 81X/82X) will be returned to the provider if the principal diagnosis on the claim is equal to a manifestation diagnosis code. Avoiding/Correcting This ErrorCorrect the diagnosis code and resubmit. Reviewed: Apr 17, 2023 |
30993 | The claim was submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. |
RTP |
Claim Error Reason Code 30993Error Description
The claim was submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. Avoiding/Correcting This Error:Verify the MBI in NGSConnex prior to using it on a claim. As a reminder either the HIC number or MBI may be submitted on a claim submitted prior to 1/1/2020. Related ContentReviewed: Apr 17, 2023 |
30993 | A claim has been submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. |
RTP |
Claim Error Reason Code 30993Error Description
A claim has been submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. Avoiding/Correcting This Error:Verify billing and if appropriate, correct and resubmit. Reviewed: Apr 17, 2023 |
31094 | When the TOB frequency code on the claim = 0 (denied bill), the total covered charges on the claim cannot be greater than zero. |
RTP |
Claim Error Reason Code 31094Error Description
When the TOB frequency code on the claim = 0 (denied bill), the total covered charges on the claim cannot be greater than zero. Avoiding/Correcting This ErrorVerify the type of bill and/or the total covered charges reported and if appropriate, correct. Reviewed: Apr 17, 2023 |
31094 | When the TOB frequency on the claim = 0, the total covered charges on the claim cannot be greater than zero. |
RTP |
Claim Error Reason Code 31094Error Description
When the TOB frequency on the claim = 0, the total covered charges on the claim cannot be greater than zero. Avoiding/Correcting This ErrorVerify the type of bill and/or the total covered charges reported. When billing for an insurance denial (3X0 bill type with condition code 21), all charges must be submitted as noncovered. There can be no covered charges on this type of billing. Reviewed: Apr 17, 2023 |
31287 | Patient status is equal to 30 on hospice claim with a ‘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. |
RTP |
Claim Error Reason Code 31287Error Description
Patient status is equal to 30 on hospice claim with a ‘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 ErrorHospices must submit claims on a monthly basis for patients who remain on service through the last day of the month. Monthly billing must conform to a calendar month (i.e., limit services to those in the same calendar month if services began midmonth). Hospices submitting more than one claim in a calendar month for the same beneficiary will have claims returned. The monthly billing requirement applies even if the patient is discharged, revokes or expires on the first of the next calendar month. For example, if a patient is admitted to hospice on August 8 and revokes the benefit on September 1, the hospice must submit two claims. A claim is submitted for dates of service August 8 to August 31 and a separate claim is submitted with dates of service September 1 to September 1. For patients who are discharged, die, or revoke during the month, please do not wait until the end of the month to submit the claim. Hospices should submit their final claims as soon as possible after the discharge, death or revocation. Related Content
Reviewed: Apr 17, 2023 |
31300 | Payer ID is equal to I, value code 42 is present, and the type of bill is not 11X, 18X, 21X, or 41X. The payor code must be equal to A, B, C, D, E, F, G, H, L, OR Z. |
RTP |
Claim Error Reason Code 31300Error Description
Payer ID is equal to I, value code 42 is present, and the type of bill is not 11X, 18X, 21X, or 41X. The payor code must be equal to A, B, C, D, E, F, G, H, L, OR Z. Avoiding/Correcting This ErrorReport one of the following Valid Payer Codes on all MSP claims: A = working aged – EGHP Reviewed: Apr 17, 2023 |
31300 | The Payer ID is equal to I, value code 42 is present, and the bill type is not 11X, 18X, 21X, or 41X. The Payer Code must be equal to A, B, C, D, E, F, G, H, L, or Z. |
RTP |
Claim Error Reason Code 31300Error Description
The Payer ID is equal to I, value code 42 is present, and the bill type is not 11X, 18X, 21X, or 41X. The Payer Code must be equal to A, B, C, D, E, F, G, H, L, or Z. Avoiding/Correcting This ErrorReport one of the following Valid Payer Codes on all MSP claims: Related ContentReviewed: Apr 17, 2023 |
31323 | Condition code 20 is present and the claim contains covered charges. |
RTP |
Claim Error Reason Code 31323Error Description
Condition code 20 is present and the claim contains covered charges. Avoiding/Correcting This ErrorSubmit only noncovered charges for demand claims (submitted with condition code 20). Covered and noncovered charges can be present on a demand claim, or a demand claim may be submitted with all noncovered charges; however, a demand claim may not be submitted with all covered charges. Reviewed: Apr 17, 2023 |
31608 | The claim contains Condition Code 04 indicating HMO enrollment. CMS requires that the claim be submitted directly to the MA plan. Nonteaching acute care hospitals, LTCH and inpatient rehabilitation facilities are required to submit covered informational only, or shadow, claims with condition code 04 to NGS for MA beneficiaries enrolled in a Medicare MA/HMO plan. The informational claim is required to capture the DSH (or LIP for IRF) calculations. IPPS teaching hospitals are required to submit covered informational only, or shadow, claims with condition codes 04 and 69 to NGS for MA beneficiaries enrolled in a Medicare MA/HMO plan to allow reimbursement for the indirect medical education payment. |
RTP |
Claim Error Reason Code 31608Error Description
The claim contains Condition Code 04 indicating HMO enrollment. CMS requires that the claim be submitted directly to the MA plan. Nonteaching acute care hospitals, LTCH and inpatient rehabilitation facilities are required to submit covered informational only, or shadow, claims with condition code 04 to NGS for MA beneficiaries enrolled in a Medicare MA/HMO plan. The informational claim is required to capture the DSH (or LIP for IRF) calculations. IPPS teaching hospitals are required to submit covered informational only, or shadow, claims with condition codes 04 and 69 to NGS for MA beneficiaries enrolled in a Medicare MA/HMO plan to allow reimbursement for the indirect medical education payment. Avoiding/Correcting This ErrorEnsure you use the correct Medicare provider number and bill type that applies to where the services were rendered. Verify the correct Medicare provider number and bill type. Correct the claim and resubmit the claim. Related Content
Reviewed: Apr 17, 2023 |
31699 | This claim has a TOB 32X other than 322, the From date is not equal to the admission date, no revenue code 042X, 043X, 044X or 055X line with covered charges is present or these revenue code lines are present but have noncovered charges, and condition code 20, 21 or 54 is not present. |
RTP |
Claim Error Reason Code 31699Error Description
This claim has a TOB 32X other than 322, the From date is not equal to the admission date, no revenue code 042X, 043X, 044X or 055X line with covered charges is present or these revenue code lines are present but have noncovered charges, and condition code 20, 21 or 54 is not present. Avoiding/Correcting This ErrorWhen billing a subsequent episode claim with no skilled services, the claim should either be an insurance denial (cc 21), a demand bill (cc 20), or if appropriate, be billed with condition code 54 (for claims received on or after 7/1/2016) to indicate no skilled services are on the claim for the billing period but there is documentation justifying billing for other covered services. Reviewed: Apr 17, 2023 |
31699 | This claim has a TOB 32X other than 322, the ‘From’ date is not equal to the admission date, no revenue code 042X, 043X, 044X or 055X line with covered charges is present or these revenue code lines are present but have noncovered charges, and condition code 20, 21 or 54 is not present. |
RTP |
Claim Error Reason Code 31699Error Description
This claim has a TOB 32X other than 322, the ‘From’ date is not equal to the admission date, no revenue code 042X, 043X, 044X or 055X line with covered charges is present or these revenue code lines are present but have noncovered charges, and condition code 20, 21 or 54 is not present. Avoiding/Correcting This ErrorWhen billing a subsequent episode claim with no skilled services, the claim should either be an insurance denial (cc 21), a demand bill (cc 20), or if appropriate, be billed with condition code 54 (for claims received on or after 7/1/2016) to indicate no skilled services are on the claim for the billing period but there is documentation justifying billing for other covered services. Reviewed: Apr 17, 2023 |
31755 | This reason code will be assigned if home health type of bill 3X2 or 3X9 is entered and the following criteria is not a match:
|
RTP |
Claim Error Reason Code 31755Error Description
This reason code will be assigned if home health type of bill 3X2 or 3X9 is entered and the following criteria is not a match:
Avoiding/Correcting This Error
Reviewed: Apr 17, 2023 |
31788 | Noncovered charges do not match between claim page 03 and 32. |
RTP |
Claim Error Reason Code 31788Error Description
Noncovered charges do not match between claim page 03 and 32. Avoiding/Correcting This ErrorVerify billing and if appropriate, correct. Note: if the original line was noncovered and you want to make covered, delete and rekey the line. Reviewed: Apr 17, 2023 |
31836 | The HCPC on the revenue code line has a status code of 'M', but the TOB is not equal to 85X. |
RTP |
Claim Error Reason Code 31836Error Description
The HCPC on the revenue code line has a status code of 'M', but the TOB is not equal to 85X. Avoiding/Correcting This ErrorChange TOB to 85X. Reviewed: Apr 17, 2023 |
32038 | Claim is TOB 32X with service through dates 1/1/2006 or greater, and a value code 61 is present with a value code amount that contains more than five positions (not including the decimal places) that represent the CBSA code but the CBSA code is either invalid or is not present on the CBSA table. |
RTP |
Claim Error Reason Code 32038Error Description
Claim is TOB 32X with service through dates 1/1/2006 or greater, and a value code 61 is present with a value code amount that contains more than five positions (not including the decimal places) that represent the CBSA code but the CBSA code is either invalid or is not present on the CBSA table. Avoiding/Correcting This ErrorVerify the validity of the CBSA code entered on your claim. The CBSA code should be entered as five numeric digits with two trailing zeroes (seven digits all together). Reviewed: Apr 17, 2023 |
32078 | For the specific type of bills listed, the claim contains one or more revenue codes that are not valid for the type of bill:
All references to TOB 73X now apply to TOB 77X. |
RTP |
Claim Error Reason Code 32078Error Description
For the specific type of bills listed, the claim contains one or more revenue codes that are not valid for the type of bill:
All references to TOB 73X now apply to TOB 77X. Avoiding/Correcting This ErrorProviders can utilize the FISS DDE system and check Option 01/13 revenue code file and find the type of bill that is applicable to their claim. The system will have a “Y” or “N” indication as to whether the revenue code is allowed for the type of claim. Verify billing and if appropriate, correct. Reviewed: Apr 17, 2023 |
32078 | The claim lines contain one or more revenue codes that are not valid for type of bill 77X:
|
RTP |
Claim Error Reason Code 32078Error Description
The claim lines contain one or more revenue codes that are not valid for type of bill 77X:
Avoiding/Correcting This ErrorEnsure that your FQHC claim follows billing requirements for PPS reimbursement. Report a billable encounter revenue code (52X, 78X, or 900) on payment code lines and qualifying visit HCPCS code lines. Claim lines reporting incident-to services should be billed using non-billable encounter revenue codes. Verify billing and if appropriate, correct. Reviewed: Apr 17, 2023 |
32103 | NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. |
RTP |
Claim Error Reason Code 32103Error Description
NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. Avoiding/Correcting This ErrorThis edit applies to the NPI number associated with the OSCAR number. Verify provider billing numbers and if appropriate, correct either NPPES or CMS-855 information. Verify all information in the NPPES. Validate that the NPI/OSCAR number pair that is being billed is set up correctly in NPPES. View/correct NPPES information by visiting the NPPES website. If the NPPES information is correct and you have included all Medicare legacy identifiers (OSCARs) in NPPES but are still experiencing problems with claims that contain a valid NPI, submit a Medicare enrollment application (i.e., CMS-855). Contact your contractor prior to submitting a CMS-855 form. Reviewed: Apr 17, 2023 |
32103 | NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. This edit applies to the NPI number associated with the OSCAR number. |
RTP |
Claim Error Reason Code 32103Error Description
NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. This edit applies to the NPI number associated with the OSCAR number. Avoiding/Correcting This ErrorThis edit applies to the NPI number associated with the OSCAR number. Verify provider billing numbers and if appropriate, correct either NPPES or CMS-855 information. Verify all information in the NPPES. Validate that the NPI/OSCAR number pair that is being billed is set up correctly in NPPES. View/correct NPPES information by visiting the NPPES website. If the NPPES information is correct and you have included all Medicare legacy identifiers (OSCARs) in NPPES but are still experiencing problems with claims that contain a valid NPI, submit a Medicare enrollment application (i.e., CMS-855). Contact your contractor prior to submitting a CMS-855 form. Reviewed: Apr 17, 2023 |
32103 | NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. |
RTP |
Claim Error Reason Code 32103Error Description
NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file. Avoiding/Correcting This ErrorThis edit applies to the NPI number associated with the OSCAR number. Verify provider billing numbers and if appropriate, correct either NPPES or CMS-855 information. Verify all information in the NPPES. Validate that the NPI/OSCAR number pair that is being billed is set up correctly in NPPES. View/correct NPPES information by visiting the NPPES website. If the NPPES information is correct and you have included all Medicare legacy identifiers (OSCARs) in NPPES but are still experiencing problems with claims that contain a valid NPI, submit a Medicare enrollment application (i.e., CMS-855). Contact your contractor prior to submitting a CMS-855 form. Reviewed: Apr 17, 2023 |
32242 | The revenue code billed is non- billable for this type of bill and covered charges are great than zero. |
RTP |
Claim Error Reason Code 32242Error Description
The revenue code billed is non- billable for this type of bill and covered charges are great than zero. Avoiding/Correcting This ErrorCheck the revenue code file in FISS DDE (01/13) Revenue code file and verify the allowance of this revenue code to the TOB. Make correction or changes as appropriate and store the claim. Reviewed: Apr 17, 2023 |
32242 | The revenue code is non-billable for this type of bill and covered charges are greater than zero. |
RTP |
Claim Error Reason Code 32242Error Description
The revenue code is non-billable for this type of bill and covered charges are greater than zero. Avoiding/Correcting This ErrorTo review this error, check the revenue code file option 01/13 and check the type of bill and the Allow column to determine if the revenue code billed is “Y” allowable for the type of bill on the returned claim. Make necessary correction and update/store the claim. Reviewed: Apr 17, 2023 |
32243 | A revenue code is present in the line item being edited, but the total charges associated with that line item are blank or equal to zero. |
RTP |
Claim Error Reason Code 32243Error Description
A revenue code is present in the line item being edited, but the total charges associated with that line item are blank or equal to zero. For claims with DOS on/after 4/1/2010, detailed line-item reporting is required. Services provided incident to the encounter should report a non billable encounter revenue code and actual charges. AIR: The claim’s encounter line revenue code should reflect a clinic visit (520), mental health visit (0900), or telehealth visit (0780) and include all charges incurred during the encounter. PPS: The claim’s encounter line revenue code should reflect a clinic visit (520) or mental health visit (0900) and include charges determined by the facility to reflect payment code charges. Avoiding/Correcting This ErrorUse claim correction option to update claim, if appropriate. Reviewed: Apr 17, 2023 |
32266 | When billing for the administration of influenza, hepatitis, or pneumococcal vaccine, you must report the HCPCS code in conjunction with revenue code 771. This applies to the administration of influenza virus vaccine HCPCS code G0008, the administration of pneumococcal vaccine HCPCS code G0009, the administration of hepatitis b vaccine HCPCS code G0010, or the Influenza A (H1N1) immunization administration HCPCS code G9141 (includes the physician counseling the patient/family). This also applies to COVID-19 vaccine administration HCPCS codes and COVID-19 Non-Administration HCPCS codes. |
RTP |
Claim Error Reason Code 32266Error Description
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 ErrorReport 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 ContentReviewed: Apr 17, 2023 |
32287 | A non-roster claim was submitted and contains more than one PPV or flu vaccine or administration on the same DOS. |
RTP |
Claim Error Reason Code 32287Error Description
A non-roster claim was submitted and contains more than one PPV or flu vaccine or administration on the same DOS. Avoiding/Correcting This Error:Remove the extra PPV or Flu vaccine code/unit from the claim. Related Content
Reviewed: Apr 17, 2023 |
32358 | Claim submitted after the revocation date on the provider file with the following criteria:
|
Rejection |
Claim Error Reason Code 32358Error Description
Claim submitted after the revocation date on the provider file with the following criteria:
Avoiding/Correcting This ErrorIf appropriate, make corrections and submit a new claim. Reviewed: Apr 17, 2023 |
32400 | A HCPCS code is required for a revenue code reported on this claim; however, the HCPCS code is missing. |
RTP |
Claim Error Reason Code 32400Error Description
A HCPCS code is required for a revenue code reported on this claim; however, the HCPCS code is missing. Avoiding/Correcting This ErrorWhen reporting revenue code 029X (Infusion pumps‒equipment), 0294 (Infusion pumps‒prescription drugs), and/or 0636 (Injectable prescription drugs), an HCPCS code is also required. Verify the revenue code(s) billed. Verify a HCPCS code is reported for every revenue code that requires one. Reviewed: Apr 17, 2023 |
32402 | The HCPCS code(s) reported on this claim have not been billed with a valid revenue code for the dates of service. |
RTP |
Claim Error Reason Code 32402Error Description
The HCPCS code(s) reported on this claim have not been billed with a valid revenue code for the dates of service. Avoiding/Correcting This ErrorWhen reporting revenue code 0250 (noninjectable prescription drugs), a HCPCS code is not reported. Instead, this revenue code is reported with the NDC. Reviewed: Apr 17, 2023 |
32402 | Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. |
RTP |
Claim Error Reason Code 32402Error Description
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 ErrorVerify 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. Reviewed: Apr 17, 2023 |
32402 | Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. |
RTP |
Claim Error Reason Code 32402Error Description
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 ErrorVerify 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. Reviewed: Apr 17, 2023 |
32403 | A HCPCS code is required for the item being edited; however, the statement coverage from/through dates on the claim fall outside of the effective/termination date for the HCPCS code on this line. Therefore, the HCPCS code is not valid for the DOS on this claim. Verify billing and if appropriate correct online providers PF9 to store claim. |
RTP |
Claim Error Reason Code 32403Error Description
A HCPCS code is required for the item being edited; however, the statement coverage from/through dates on the claim fall outside of the effective/termination date for the HCPCS code on this line. Therefore, the HCPCS code is not valid for the DOS on this claim. Verify billing and if appropriate correct online providers PF9 to store claim. Avoiding/Correcting This ErrorVerify that HCPCS code is valid for the DOS in question prior to billing. Related Content
Reviewed: Apr 17, 2023 |
32403 | A HCPCS code is required for the item being edited; however, the statement coverage from/through dates on the claim fall outside of the effective/termination date for the HCPCS code on this line. Therefore, the HCPCS code is not valid for the DOS on this claim. |
RTP |
Claim Error Reason Code 32403Error Description
A HCPCS code is required for the item being edited; however, the statement coverage from/through dates on the claim fall outside of the effective/termination date for the HCPCS code on this line. Therefore, the HCPCS code is not valid for the DOS on this claim. Avoiding/Correcting This ErrorVerify that HCPCS code is valid for the DOS in question prior to billing. Related Content
Reviewed: Apr 17, 2023 |
32403 | According to the revenue code table, a HCPCS code is required for the line item being edited; however, the ‘from’ and/or ‘through’ dates on the claim fall outside of the effective/termination dates for the HCPCS code on the HCPCS table file. |
RTP |
Claim Error Reason Code 32403Error Description
According to the revenue code table, a HCPCS code is required for the line item being edited; however, the ‘from’ and/or ‘through’ dates on the claim fall outside of the effective/termination dates for the HCPCS code on the HCPCS table file. Avoiding/Correcting This ErrorCorrect the HCPCS code and resubmit. Reviewed: Apr 17, 2023 |
32404 | Either the HCPCS code is missing from the claim (or) is not on file for one of the following reason(s):
|
RTP |
Claim Error Reason Code 32404Error Description
Either the HCPCS code is missing from the claim (or) is not on file for one of the following reason(s):
Verify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable HCPCS codes will be displayed based on DOS. Avoiding/Correcting This ErrorUse the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim. Reviewed: Apr 17, 2023 |
32405 | The units billed are more than one (1) for an automated profile, hematology profile or organ and disease panel HCPCS and the claim is for one date of service. |
RTP |
Claim Error Reason Code 32405Error Description
The units billed are more than one (1) for an automated profile, hematology profile or organ and disease panel HCPCS and the claim is for one date of service. Avoiding/Correcting This ErrorVerify the HCPCS codes and units of service billed. Correct claims as necessary. Reviewed: Apr 17, 2023 |
32415 | Condition code 'A6' is required when billing the influenza and/or pneumococcal vaccine and/or COVID-19 vaccine and their related administration codes. |
RTP |
Claim Error Reason Code 32415Error Description
Condition code 'A6' is required when billing the influenza and/or pneumococcal vaccine and/or COVID-19 vaccine and their related administration codes. Avoiding/Correcting This ErrorAppend the “A6” condition code to the claim and F9 or resubmit. Related Content
Reviewed: Apr 17, 2023 |
32415 | Condition code ‘A6’ is required when one or more of the following HCPCS are present on the claim: HCPCS Q0124 with from date less than 1/1/1995 or 90655–90660, 90724, 90732, G0008, G0009 or G9141 or HCPCS G9017–G9020, G9033–G9036, and from date 12/1/2004 through 5/31/2005. HCPCS 90658 is termed effective 12/31/2010 and replaced by HCPCS Q2035–Q2039 effective 10/1/2010.
|
RTP |
Claim Error Reason Code 32415Error Description
Condition code ‘A6’ is required when one or more of the following HCPCS are present on the claim: HCPCS Q0124 with from date less than 1/1/1995 or 90655–90660, 90724, 90732, G0008, G0009 or G9141 or HCPCS G9017–G9020, G9033–G9036, and from date 12/1/2004 through 5/31/2005. HCPCS 90658 is termed effective 12/31/2010 and replaced by HCPCS Q2035–Q2039 effective 10/1/2010.
Avoiding/Correcting This ErrorVerify billing and correct where appropriate. Related Content
Reviewed: Apr 17, 2023 |
32415 | Condition code 'A6' is required when a vaccine HCPCS code is present on the claim. |
RTP |
Claim Error Reason Code 32415Error Description
Condition code 'A6' is required when a vaccine HCPCS code is present on the claim. Avoiding/Correcting This ErrorHCPCS code for vaccines can be found on under the Medicare Preventive Services. Reviewed: Apr 17, 2023 |
32415 | Condition code ‘A6’ is required when one or more of the following HCPCS/CPT codes are present on the claim:
|
RTP |
Claim Error Reason Code 32415Error Description
Condition code ‘A6’ is required when one or more of the following HCPCS/CPT codes are present on the claim:
Avoiding/Correcting This ErrorIf reporting an influenza or pneumococcal vaccines along with a billable encounter, include the A6 condition code on the claim. Verify billing and correct where appropriate. Related ContentReviewed: Apr 17, 2023 |
32511 | NDC information is missing or present on the claim but is missing one of the required elements NDC, quantity qualifier or quantity. |
RTP |
Claim Error Reason Code 32511Error Description
NDC information is missing or present on the claim but is missing one of the required elements NDC, quantity qualifier or quantity. Avoiding/Correcting This ErrorVerify billing and if appropriate, correct and resubmit. Related ContentReviewed: Apr 17, 2023 |
32511 | NDC information is missing or present on the claim but is missing one of the required elements (NDC, quantity qualifier or quantity). |
RTP |
Claim Error Reason Code 32511Error Description
NDC information is missing or present on the claim but is missing one of the required elements (NDC, quantity qualifier or quantity). Avoiding/Correcting This ErrorCorrect the NDC information and resubmit. Related ContentReviewed: Apr 17, 2023 |
32710 | One or more diagnosis codes are equal. |
RTP |
Claim Error Reason Code 32710Error Description
One or more diagnosis codes are equal. Avoiding/Correcting This ErrorVerify the diagnosis codes reported on your claim and ensure the same information hasn’t been reported twice. Reviewed: Apr 17, 2023 |
32959 | The provider type and bill type are an invalid combination.
|
RTP |
Claim Error Reason Code 32959Error Description
The provider type and bill type are an invalid combination.
Avoiding/Correcting This ErrorEnsure you use the correct Medicare provider number and bill type that applies to where the services were rendered. Verify the correct Medicare provider number and bill type. Correct the claim and resubmit the claim. Related Content
Reviewed: Apr 17, 2023 |
34002 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34002Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorIf this is correct, follow MSP billing guidelines and submit the claim accordingly. If this is incorrect. as part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Address for general MSP correspondence: Fax: 405-869-3307 In addition, providers should utilize all available/applicable condition codes, occurrence codes, and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF. Related ContentReviewed: Apr 17, 2023 |
34072 | Claims were submitted as Medicare primary and a positive working elderly record exists at CWF. The claim was submitted with an occurrence code 18, however the retirement date is the same as or prior to the effective date of the CWF MSPA record/s or is equal to the claim from date. The occurrence code 25 date benefits terminated by the primary payer is prior to dates of service and not equal to the occurrence code 18 (Retirement date). Or, occurrence code 25 is within or after the dates of service but there is an MSPA record which has the spouse as the policy holder. |
RTP |
Claim Error Reason Code 34072Error Description
Claims were submitted as Medicare primary and a positive working elderly record exists at CWF. The claim was submitted with an occurrence code 18, however the retirement date is the same as or prior to the effective date of the CWF MSPA record/s or is equal to the claim from date. The occurrence code 25 date benefits terminated by the primary payer is prior to dates of service and not equal to the occurrence code 18 (Retirement date). Or, occurrence code 25 is within or after the dates of service but there is an MSPA record which has the spouse as the policy holder. Avoiding/Correcting This ErrorProviders can currently check MSPA records thru HIQA, NGSConnex. If the records on CWF need updated this is handled by BCRC. Verify the retirement date (occurrence code 18) and make changes if needed. If the retirement date is correct, add coding to indicate the date was verified and correct and resubmit the claim. Clarify if occurrence code 25 is for the record of the spouse and add claim coding and resubmit the claims.
Reviewed: Apr 17, 2023 |
34281 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. |
Rejection |
Claim Error Reason Code 34281Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. Avoiding/Correcting This ErrorCheck Medicare records to identify the proper order of payers and verify Medicare should be primary. If records are correct: reformat and resubmit as Medicare secondary. If the records are incorrect, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Related ContentReviewed: Apr 17, 2023 |
34281 | Claim submitted as Medicare Primary and a positive working elderly record exists at CWF. |
Rejection |
Claim Error Reason Code 34281Error Description
Claim submitted as Medicare Primary and a positive working elderly record exists at CWF. Avoiding/Correcting This ErrorCheck Medicare records to identify the proper order of payers and verify Medicare should be primary. If records are correct: reformat and resubmit as Medicare secondary. If the records are incorrect, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Related ContentReviewed: Apr 17, 2023 |
34293 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34293Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct: reformat as secondary and resubmit. If the records are incorrect, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Medicare ‒ MSP General Correspondence Reviewed: Apr 17, 2023 |
34295 | Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34295Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct, reformat as secondary and resubmit. If records are not correct and you have information that disputes the records, please contact the Benefits Coordination & Recovery Center: Medicare - MSP General Correspondence Telephone number: 855-798-2627 Reviewed: Apr 17, 2023 |
34538 | The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason Code 34538Error Description
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
Related Content
Reviewed: Apr 17, 2023 |
34538 | The claim was submitted as Medicare primary and a positive working aged record exists at CWF. |
Rejection |
Claim Error Reason Code 34538Error Description
The claim was submitted as Medicare primary and a positive working aged record exists at CWF. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct, reformat and resubmit as secondary. If you have information that disputes open records, please contact the BCRC at 855-798-2627. Related Content
Reviewed: Apr 17, 2023 |
34538 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34538Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorIf this is correct: Follow MSP billing guidelines and submit the claim accordingly. If this is incorrect: As part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records - we are not the Medicare office that manages those files. Please contact the BCRC: Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays)
Address for general MSP correspondence: Fax: 405-869-3307 In addition, providers should utilize all available/applicable condition codes, occurrence codes and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF. Related ContentReviewed: Apr 17, 2023 |
34538 | The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason Code 34538Error Description
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
Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates. Related ContentReviewed: Apr 17, 2023 |
34538 | The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason Code 34538Error Description
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
Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates. Related Content
Reviewed: Apr 17, 2023 |
34538 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34538Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorIf this is correct: Follow MSP billing guidelines and submit the claim accordingly. If this is incorrect: As part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records—we are not the Medicare office that manages those files. Please contact the BCRC: Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays)
Address for general MSP correspondence: Fax: 405-869-3307 In addition, providers should utilize all available/applicable condition codes, occurrence codes, and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF. Related ContentReviewed: Apr 17, 2023 |
34540 | The claim was submitted as Medicare primary but an open MSP Disability record (VC = 43; Payer Code = G) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date/last date on which beneficiary or spouse was actively employed). |
Rejection |
Claim Error Reason Code 34540Error Description
The claim was submitted as Medicare primary but an open MSP Disability record (VC = 43; Payer Code = G) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date/last date on which beneficiary or spouse was actively employed). Avoiding/Correcting This Error
Do not resubmit claims rejected for reason code 34540 as they will be rejected as duplicates. Related ContentReviewed: Apr 17, 2023 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. This claim should be submitted to the primary insurer. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. This claim should be submitted to the primary insurer. Avoiding/Correcting This ErrorIf the records are correct, reformat as Medicare secondary; the Medicare Secondary Payer page on our website provides direction. If the records need to be updated, you will need to contact the BCRC at 855-798-2627 or written inquiry: MSP General Correspondence Reviewed: Apr 17, 2023 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct: reformat as secondary and resubmit. If records are not correct and you have information that disputes the records, please contact the BCRC, Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Address for general MSP correspondence: Medicare - MSP general correspondence
Reviewed: Apr 17, 2023 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct: reformat as secondary and resubmit. If records are not correct and you have information that disputes the records, please contact the BCRC: Medicare - Coordination of Benefits Toll free: 800-999-1118 You can find additional information on VA transfers in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 60. (319 KB) Reviewed: Apr 17, 2023 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorIf this is correct, follow MSP billing guidelines and submit the claim accordingly. If this is incorrect. as part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records, please contact the BCRC Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Address for general MSP correspondence: Fax: 405-869-3307 In addition, providers should utilize all available/applicable condition codes, occurrence codes, and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF. Related ContentReviewed: Apr 17, 2023 |
34923 | The line-item date of service for noncovered units for revenue codes 651, 652, 655 or 656 must be within the OSC 77 date range, and the total noncovered units for revenue codes 651, 652, 655 or 656 must equal the noncovered days reflected in OSC 77; or occurrence span code 77 is present and revenue code 651, 652, 655 or 656 is not present with noncovered units equal to the noncovered days reflected in the OSC 77. |
RTP |
Claim Error Reason Code 34923Error Description
The line-item date of service for noncovered units for revenue codes 651, 652, 655 or 656 must be within the OSC 77 date range, and the total noncovered units for revenue codes 651, 652, 655 or 656 must equal the noncovered days reflected in OSC 77; or occurrence span code 77 is present and revenue code 651, 652, 655 or 656 is not present with noncovered units equal to the noncovered days reflected in the OSC 77. Avoiding/Correcting This ErrorWhen reporting an OSC 77, all line items with dates of service that fall within the span must be reported as noncovered. Verify the line item date(s) of service and the occurrence span code 77 date(s) and if appropriate, correct. Reviewed: Apr 17, 2023 |
34952 | For dates of service on or after 4/1/2014, HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present and the service facility location NPI is blank or invalid. |
RTP |
Claim Error Reason Code 34952Error Description
For dates of service on or after 4/1/2014, HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present and the service facility location NPI is blank or invalid. Avoiding/Correcting This ErrorIf HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present on the claim, an NPI is required to identify the other facility where the patient was receiving care. If the patient received care in a privately-owned and run facility (non-Medicare certified facility), do not report one of the above Q-codes, instead, report Q5009. Reviewed: Apr 17, 2023 |
34952 | For dates of service on or after 4/1/2014, HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present and the service facility location NPI is blank or invalid. |
RTP |
Claim Error Reason Code 34952Error Description
For dates of service on or after 4/1/2014, HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present and the service facility location NPI is blank or invalid. Avoiding/Correcting This ErrorIf HCPCS code Q5003, Q5004, Q5005, Q5006 (when not the same as the billing hospice), Q5007 or Q5008 is present on the claim, an NPI is required to identify the other facility where the patient was receiving care. If the patient received care in a privately-owned and run facility (non-Medicare certified facility), do not report one of the above Q-codes, instead, report Q5009. Reviewed: Apr 17, 2023 |
34992 | The number of occurrence code 50(s) do not match the number of revenue code 0022 lines. Revenue lines with HIPPS code ZZZZZ are excluded. |
RTP |
Claim Error Reason Code 34992Error Description
The number of occurrence code 50(s) do not match the number of revenue code 0022 lines. Revenue lines with HIPPS code ZZZZZ are excluded. Avoiding/Correcting This ErrorVerify the occurrence codes billed. Correct claims as necessary. Reviewed: Apr 17, 2023 |
36188 | For dates of service 4/1/2015 and greater, value code 78 is only valid on the following types of bills: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X and 85X. |
RTP |
Claim Error Reason Code 36188Error Description
For dates of service 4/1/2015 and greater, value code 78 is only valid on the following types of bills: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X and 85X. Avoiding/Correcting This ErrorRemove the value code 78 from the hospice claim (TOB 81X/82X) and resubmit the claim. Reviewed: Apr 17, 2023 |
36458 | Effective for dates or service on or after 10/1/2015, hospice claim has an invalid CBSA. Note: CBSAs in the 50XXX range are valid for dates of service on or after 10/1/2015 and prior to 10/1/2006. |
RTP |
Claim Error Reason Code 36458Error Description
Effective for dates or service on or after 10/1/2015, hospice claim has an invalid CBSA. Note: CBSAs in the 50XXX range are valid for dates of service on or after 10/1/2015 and prior to 10/1/2006. Avoiding/Correcting This ErrorCorrect the CBSA code and resubmit. Reviewed: Apr 17, 2023 |
36458 | Effective for dates or service on or after 10/1/2015, hospice claim has an invalid CBSA. Note: CBSAs in the 50XXX range are valid for dates of service on or after 10/1/2015 and prior to 10/1/2006 |
RTP |
Claim Error Reason Code 36458Error Description
Effective for dates or service on or after 10/1/2015, hospice claim has an invalid CBSA. Note: CBSAs in the 50XXX range are valid for dates of service on or after 10/1/2015 and prior to 10/1/2006 Avoiding/Correcting This ErrorCorrect the CBSA code and resubmit. Reviewed: Apr 17, 2023 |
36636 | HCPCS codes 82310, 82435, 82374, 82565, 82947, 84132, 84295 and 84520 are billed for the same line item date of service. These HCPCS codes should not be submitted separately. If these services were performed, submit as organ disease panel HCPCS code 80048. |
RTP |
Claim Error Reason Code 36636Error Description
HCPCS codes 82310, 82435, 82374, 82565, 82947, 84132, 84295 and 84520 are billed for the same line item date of service. These HCPCS codes should not be submitted separately. If these services were performed, submit as organ disease panel HCPCS code 80048. Avoiding/Correcting This Error:Consistent with NCCI edits, when a laboratory performs all of the tests included in one of the panel CPT codes, they shall report the CPT code for the panel. In these instances, it is not appropriate to report the individual tests. Claims submitted with individual lab tests that are part of a specific panel will be returned to the provider as unprocessable. Related ContentProviders should refer to the NCCI Policy Manual Chapter 1, Section N – Laboratory Panel and Chapter 10, Section C – Organ or Disease Oriented Panels for complete billing and coding information. NCCI Policy Manual for Medicare (ZIP) Reviewed: Apr 17, 2023 |
37098 | FQHC PPS supplemental rate is not present for the MA-plan. |
RTP |
Claim Error Reason Code 37098Error Description
FQHC PPS supplemental rate is not present for the MA-plan. Avoiding/Correcting This ErrorSubmit an estimate of the average MA payments (per visit basis) for covered FQHC services to NGS (for the first two rate years). Submit a documented estimate of the average per visit payment for MA enrollees, for each MA plan you contract with, and any other information as may be required to enable NGS to accurately establish an interim supplemental payment. Expected payments from the MA organization would only be used until actual MA revenue and visits collected on the FQHC’s cost report can be used to establish the amount of the supplemental payment. Related ContentCMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers, Section 60.4 - Billing for Supplemental Payments to FQHCs under Contract with Medicare Advantage (MA) Plans Reviewed: Apr 17, 2023 |
38031 | This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
|
Rejection |
Claim Error Reason Code 38031Error Description
This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
Avoiding/Correcting This ErrorPrior 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. It is important to note that providers should not call the Provider Contact Center for this information, as they are not allowed to advise providers of claim status. When it is necessary for additional charges to be submitted to Medicare for a patient for a specific date of service after a claim has been submitted, wait for the original claim to finalize and then adjust (TOB XX7) the originally-processed claim instead of submitting a new claim with the additional charges. Check for another (duplicate) claim. If the original claim is correct, no further action is necessary. If the original claim needs to be adjusted, adjust the original claim, and resubmit to the MAC. If the current claim is missing information showing it should not be a duplicate, make corrections and submit a new claim. Reviewed: Apr 17, 2023 |
38031 | This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
|
Rejection |
Claim Error Reason Code 38031Error Description
This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
Avoiding/Correcting This ErrorPrior 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. It is important to note that providers should not call the Provider Contact Center for this information, as they are not allowed to advise providers of claim status. When it is necessary for additional charges to be submitted to Medicare for a patient for a specific date of service after a claim has been submitted, wait for the original claim to finalize and then adjust (TOB XX7) the originally-processed claim instead of submitting a new claim with the additional charges. Check for another (duplicate) claim. If the original claim is correct, no further action is necessary. If the original claim needs to be adjusted, adjust the original claim, and resubmit to the MAC. If the current claim is missing information showing it should not be a duplicate, make corrections and submit a new claim. Reviewed: Apr 17, 2023 |
38031 | This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
|
Rejection |
Claim Error Reason Code 38031Error Description
This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
Avoiding/Correcting This ErrorVerify 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. Reviewed: Apr 17, 2023 |
38032 | The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. |
Rejection |
Claim Error Reason Code 38032Error Description
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 ErrorIf 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. Reviewed: Apr 17, 2023 |
38032 | This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
|
Rejection |
Claim Error Reason Code 38032Error Description
This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Apr 17, 2023 |
38032 | The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. |
Rejection |
Claim Error Reason Code 38032Error Description
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 ErrorPrior to submitting a claim, ensure you have received the charges from all departments for the DOS so you can submit one claim with all of the services rendered. For claims rejected with 38200, wait for the original claim to complete processing, then adjust the processed claim to add/update services/charges instead of submitting a new claim with the additional charges. Reviewed: Apr 17, 2023 |
38032 | This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
|
Rejection |
Claim Error Reason Code 38032Error Description
This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Apr 17, 2023 |
38037 | This outpatient claim contains service dates that equal or overlap a previously submitted outpatient claim from your facility. At least one of the revenue codes or HCPCS codes match. |
Rejection |
Claim Error Reason Code 38037Error Description
This outpatient claim contains service dates that equal or overlap a previously submitted outpatient claim from your facility. At least one of the revenue codes or HCPCS codes match. Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Apr 17, 2023 |
38038 | Whether any revenue code lines are equal or not, OPPS bill types (12X, 13X, 14X, 76X, 75X, 34X, or any bill containing condition code 07) cannot have overlapping dates when the provider numbers are equal, unless condition code G0 or 20 or 21 is present on the claim. |
RTP |
Claim Error Reason Code 38038Error Description
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 ErrorCheck OPPS claims for potential overlapping dates of service prior to claim submission and bill accordingly An adjustment bill must be submitted
Reviewed: Apr 17, 2023 |
38050 | This claim is a duplicate of a previously submitted home health claim. The first two positions of the TOB are 32X, 33X or 34X and the following fields on the history and processing claim are the same.
|
Rejection |
Claim Error Reason Code 38050Error Description
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.
Avoiding/Correcting This ErrorCheck your remittance advice or the claims processing system for a previously submitted/processed claim before submitting any new billing. Reviewed: Apr 17, 2023 |
38050 | This claim is a duplicate of a previously submitted home health claim. The first two positions of the TOB are 32X, 33X or 34X and the following fields on the history and processing claim are the same.
|
Rejection |
Claim Error Reason Code 38050Error Description
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.
Avoiding/Correcting This ErrorCheck your remittance advice or the claims processing system for a previously submitted/processed claim before submitting any new billing. Reviewed: Apr 17, 2023 |
38054 | This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38054Error Description
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
Reviewed: Apr 17, 2023 |
38054 | This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38054Error Description
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
Reviewed: Apr 17, 2023 |
38055 | This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38055Error Description
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
Reviewed: Apr 17, 2023 |
38092 | This outpatient claim is a duplicate to another outpatient claim that has multi-channel lab HCPCS code(s) with matching line item dates of service for the lab charges. |
Rejection |
Claim Error Reason Code 38092Error Description
This outpatient claim is a duplicate to another outpatient claim that has multi-channel lab HCPCS code(s) with matching line item dates of service for the lab charges. Avoiding/Correcting This ErrorVerify the from and through dates, the HCPCS codes and the line item dates of service for the lab charges.
Reviewed: Apr 17, 2023 |
38111 | This claim is a duplicate of a claim on history where the dates of services are equal, the provider numbers are equal and HCPCS 90655, 90656, 90657, 90658, 90659, 90660, 90724 or 90732 are present on both claims. |
Rejection |
Claim Error Reason Code 38111Error Description
This claim is a duplicate of a claim on history where the dates of services are equal, the provider numbers are equal and HCPCS 90655, 90656, 90657, 90658, 90659, 90660, 90724 or 90732 are present on both claims. Avoiding/Correcting This ErrorCheck the claims submitted by your agency for the patient:
Reviewed: Apr 17, 2023 |
38117 | All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. |
RTP |
Claim Error Reason Code 38117Error Description
All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. Avoiding/Correcting This ErrorIf there is a prior claim for this admission pending in our system, verify the admission date and from date on this claim. If admission and from dates are correctly reported, please hold this claim until the pending bill has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may resubmit the next claim. Prior to billing, verify the admission date and from date on this claim. Verify that claims are submitted in date of service order. Verify previous claim has completed processing and has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may submit the next claim. Related ContentReviewed: Apr 17, 2023 |
38117 | All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. |
RTP |
Claim Error Reason Code 38117Error Description
All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. Avoiding/Correcting This ErrorIf there is a prior claim for this admission pending in our system, verify the admission date and from date on this claim. If admission and from dates are correctly reported, please hold this claim until the pending bill has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may resubmit the next claim. Prior to billing, verify the admission date and from date on this claim. Verify that claims are submitted in date of service order. Verify previous claim has completed processing and has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may submit the next claim. Related ContentReviewed: Apr 17, 2023 |
38119 | Effective with admissions on and after 4/1/1995, all inpatient SNF and non-PPS bills must be processed in sequence. We have not received the claim immediately preceding the dates of service on this bill. |
RTP |
Claim Error Reason Code 38119Error Description
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
Reviewed: Apr 17, 2023 |
38119 | This claim reports DOS that are part of a continuing stay. We have not received the claim immediately preceding the DOS on this bill. |
RTP |
Claim Error Reason Code 38119Error Description
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 ErrorSubmit continuing-stay claims one month at a time and allow the claim to process before submitting the next month’s claim.
Reviewed: Apr 17, 2023 |
38157 | This RAP is a duplicate to a paid RAP or to a paid, suspended or denied home health claim for the same provider, same Medicare number and same statement ‘from’ date and does not contain a cancel date. |
RTP |
Claim Error Reason Code 38157Error Description
This RAP is a duplicate to a paid RAP or to a paid, suspended or denied home health claim for the same provider, same Medicare number and same statement ‘from’ date and does not contain a cancel date. Avoiding/Correcting This ErrorThis reason code is applied when a RAP and final claim are submitted at the same time, when a RAP is submitted after one has already processed, or when a RAP is resubmitted after the final episode claim has processed. To avoid this problem, verify the information already in the claims processing system before submitting your billing. Wait to submit the final episode claim until the RAP has finalized processing. Reviewed: Apr 17, 2023 |
38157 | This RAP is a duplicate of a paid RAP or paid, suspended or denied home health claim for the same provider, Medicare number and statement from date without a cancel date. |
Rejection |
Claim Error Reason Code 38157Error Description
This RAP is a duplicate of a paid RAP or paid, suspended or denied home health claim for the same provider, Medicare number and statement from date without a cancel date. Avoiding/Correcting This ErrorThis reason code may be applied when a RAP and final claim are submitted at the same time or when a RAP is submitted after the episode claim has been processed or when a RAP is already in the system. If the RAP and claim were submitted at the same time, and no RAP has yet been processed for the episode, resubmit the RAP and wait for it to process before submitting the final claim for the episode. If the RAP already on the system needs to be corrected, cancel the processed RAP and after it has canceled, submit the RAP with corrected information. Reviewed: Apr 17, 2023 |
38157 | This RAP is a duplicate of a paid RAP or paid, suspended or denied home health claim for the same provider, Medicare number and statement from date without a cancel date. |
Rejection |
Claim Error Reason Code 38157Error Description
This RAP is a duplicate of a paid RAP or paid, suspended or denied home health claim for the same provider, Medicare number and statement from date without a cancel date. Avoiding/Correcting This ErrorThis reason code may be applied when a RAP and final claim are submitted at the same time or when a RAP is submitted after the episode claim has been processed or when a RAP is already in the system. If the RAP and claim were submitted at the same time, and no RAP has yet been processed for the episode, resubmit the RAP and wait for it to process before submitting the final claim for the episode. If the RAP already on the system needs to be corrected, cancel the processed RAP and after it has canceled, submit the RAP with corrected information. Reviewed: Apr 17, 2023 |
38200 | This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
|
Rejection |
Claim Error Reason Code 38200Error Description
This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorAlways 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:
Reviewed: Apr 17, 2023 |
38200 | This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
|
Rejection |
Claim Error Reason Code 38200Error Description
This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorThis reason code may be applied when a RAP and final claim are submitted at the same time or when a RAP is submitted after the episode claim has been processed or when a RAP is already in the system. If the RAP and claim were submitted at the same time, and no RAP has yet been processed for the episode, resubmit the RAP and wait for it to process before submitting the final claim for the episode. If the RAP already on the system needs to be corrected, cancel the processed RAP and after it has canceled, submit the RAP with corrected information. Reviewed: Apr 17, 2023 |
38200 | This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
|
Rejection |
Claim Error Reason Code 38200Error Description
This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorThis reason code may be applied when a RAP and final claim are submitted at the same time or when a RAP is submitted after the episode claim has been processed or when a RAP is already in the system. If the RAP and claim were submitted at the same time, and no RAP has yet been processed for the episode, resubmit the RAP and wait for it to process before submitting the final claim for the episode. If the RAP already on the system needs to be corrected, cancel the processed RAP and after it has canceled, submit the RAP with corrected information. Reviewed: Apr 17, 2023 |
38308 | The claim contains condition code 20 and the dates of service overlap a history claim, the providers are the same on the history and incoming claim, the charges are noncovered on the history claim. |
Rejection |
Claim Error Reason Code 38308Error Description
The claim contains condition code 20 and the dates of service overlap a history claim, the providers are the same on the history and incoming claim, the charges are noncovered on the history claim. Avoiding/Correcting This ErrorThis edit was identified as a system error. Home health demand claims submitted with condition code 20 that did not go through the ADR process and received this reason code should have been resubmitted. If the RAP for the claim was auto-canceled by the system, it needed to be resubmitted and processed before the claim that hit the 38308 error was resubmitted. Reviewed: Apr 17, 2023 |
38308 | The claim contains condition code 20 and the dates of service overlap a history claim, the providers are the same on the history and incoming claim, the charges are noncovered on the history claim. |
Rejection |
Claim Error Reason Code 38308Error Description
The claim contains condition code 20 and the dates of service overlap a history claim, the providers are the same on the history and incoming claim, the charges are noncovered on the history claim. Avoiding/Correcting This ErrorThis edit was identified as a system error. Home health demand claims submitted with condition code 20 that did not go through the ADR process and received this reason code should have been resubmitted. If the RAP for the claim was auto-canceled by the system, it needed to be resubmitted and processed before the claim that hit the 38308 error was resubmitted. Reviewed: Apr 17, 2023 |
38312 | FQHC PPS claim with a LIDOS that matches another LIDOS on a previously submitted claim and all of the following match:
If appropriate make corrects and resubmit a new claim to the MAC. |
Rejection |
Claim Error Reason Code 38312Error Description
FQHC PPS claim with a LIDOS that matches another LIDOS on a previously submitted claim and all of the following match:
If appropriate make corrects and resubmit a new claim to the MAC. Avoiding/Correcting This ErrorBefore submission of the claim, ensure that no other claim was previously billed and processed with the same line item date of service. If another claim was processed with the same line item date of service, an adjustment to the processed claim will need to be submitted as an XX7 type of bill to include all charges for claim. Reviewed: Apr 17, 2023 |
38312 | This FQHC PPS claim reports a line item DOS that matches another line item DOS on a previously submitted claim for the same beneficiary. |
Rejection |
Claim Error Reason Code 38312Error Description
This FQHC PPS claim reports a line item DOS that matches another line item DOS on a previously submitted claim for the same beneficiary. Avoiding/Correcting This ErrorMake sure services provided are submitted for reimbursement once. If additional services need to be added to a submitted claim, wait for that claim to process. Then adjust the processed claim to add the additional services. Reviewed: Apr 17, 2023 |
39011 | This claim or adjustment has failed the timeliness of submission edit. Claims with dates of service on or prior to 12/31/2009 must have been received prior to 12/31/2010. Claims with dates of service 1/1/2010 and beyond must be submitted within one calendar year from the claim’s date of service. For example if the claim DOS = 5/31/2017, then the claim must be received by 5/31/2018. The time limit for filing may be extended up to six months following notification to the provider or beneficiary of a Medicare Program administrative error. Claim remarks and date of notification are required to request the six month extension. Example: If untimely submission is due to a Medicaid retro buy-in to Medicare, that must be indicated in Remarks along with the date you were notified of the buy-in. If it has been greater than one year from the date of the original determination or redetermination and the requested adjustment is based on the provider identification of clerical error, this must be submitted to the Appeals Department with a request for reopening form indicating the error made and the correction needed. Medicare does not consider it “good cause” for reopening after the one year period when a third party payer mistakenly paid primary and now alleges that Medicare should have been primary. |
Rejection |
Claim Error Reason Code 39011Error Description
This claim or adjustment has failed the timeliness of submission edit. Claims with dates of service on or prior to 12/31/2009 must have been received prior to 12/31/2010. Claims with dates of service 1/1/2010 and beyond must be submitted within one calendar year from the claim’s date of service. For example if the claim DOS = 5/31/2017, then the claim must be received by 5/31/2018. The time limit for filing may be extended up to six months following notification to the provider or beneficiary of a Medicare Program administrative error. Claim remarks and date of notification are required to request the six month extension. Example: If untimely submission is due to a Medicaid retro buy-in to Medicare, that must be indicated in Remarks along with the date you were notified of the buy-in. If it has been greater than one year from the date of the original determination or redetermination and the requested adjustment is based on the provider identification of clerical error, this must be submitted to the Appeals Department with a request for reopening form indicating the error made and the correction needed. Medicare does not consider it “good cause” for reopening after the one year period when a third party payer mistakenly paid primary and now alleges that Medicare should have been primary. Avoiding/Correcting This ErrorAll claims must follow the timely filing guidelines. Keep in mind that home health RAPs and claims must be submitted within one calendar year of the episode end date. Reviewed: Apr 17, 2023 |
39011 | This claim or adjustment has failed the timeliness of submission edit. Claims with dates of service on or prior to 12/31/2009 must have been received prior to 12/31/2010. Claims with dates of service 1/1/2010 and beyond must be submitted within one calendar year from the claim’s date of service. For example if the claim DOS = 5/31/2017, then the claim must be received by 5/31/2018. The time limit for filing may be extended up to six months following notification to the provider or beneficiary of a Medicare Program administrative error. Claim remarks and date of notification are required to request the six month extension. Example: If untimely submission is due to a Medicaid retro buy-in to Medicare, that must be indicated in Remarks along with the date you were notified of the buy-in. If it has been greater than one year from the date of the original determination or redetermination and the requested adjustment is based on the provider identification of clerical error, this must be submitted to the Appeals Department with a request for reopening form indicating the error made and the correction needed. Medicare does not consider it “good cause” for reopening after the one year period when a third party payer mistakenly paid primary and now alleges that Medicare should have been primary. |
Rejection |
Claim Error Reason Code 39011Error Description
This claim or adjustment has failed the timeliness of submission edit. Claims with dates of service on or prior to 12/31/2009 must have been received prior to 12/31/2010. Claims with dates of service 1/1/2010 and beyond must be submitted within one calendar year from the claim’s date of service. For example if the claim DOS = 5/31/2017, then the claim must be received by 5/31/2018. The time limit for filing may be extended up to six months following notification to the provider or beneficiary of a Medicare Program administrative error. Claim remarks and date of notification are required to request the six month extension. Example: If untimely submission is due to a Medicaid retro buy-in to Medicare, that must be indicated in Remarks along with the date you were notified of the buy-in. If it has been greater than one year from the date of the original determination or redetermination and the requested adjustment is based on the provider identification of clerical error, this must be submitted to the Appeals Department with a request for reopening form indicating the error made and the correction needed. Medicare does not consider it “good cause” for reopening after the one year period when a third party payer mistakenly paid primary and now alleges that Medicare should have been primary. Avoiding/Correcting This ErrorAll claims must follow the timely filing guidelines. Keep in mind that home health RAPs and claims must be submitted within one calendar year of the episode end date. Reviewed: Apr 17, 2023 |
39721 | The requested nonmedical information was not received timely. |
Rejection |
Claim Error Reason Code 39721Error Description
The requested nonmedical information was not received timely. Avoiding/Correcting This ErrorTo have this claim considered for payment submit a new electronic billing with the requested information. Reviewed: Apr 17, 2023 |
39721 | The requested nonmedical information was not received timely. |
Rejection |
Claim Error Reason Code 39721Error Description
The requested nonmedical information was not received timely. Avoiding/Correcting This ErrorTo have this claim considered for payment, submit a new electronic billing with the requested information. Reviewed: Apr 17, 2023 |
39721 | The requested nonmedical information was not received timely. |
Rejection |
Claim Error Reason Code 39721Error Description
The requested nonmedical information was not received timely. Avoiding/Correcting This ErrorTo have this claim considered for payment, submit a new electronic billing with the requested information. Reviewed: Apr 17, 2023 |
39928 | Each line of charges on this claim has been denied by medical review. |
Denial |
Claim Error Reason Code 39928Error Description
Each line of charges on this claim has been denied by medical review. Avoiding/Correcting This ErrorTo 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. Reviewed: Apr 17, 2023 |
39928 | Each line of charges on this claim has been denied by medical review. |
Denial |
Claim Error Reason Code 39928Error Description
Each line of charges on this claim has been denied by medical review. Avoiding/Correcting This Error
Reviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied Avoiding/Correcting This ErrorVerify 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:
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 ContentReviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, return to the claim and follow these steps:
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. Reviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Providers can access MAP171D for line item detail information:
Reviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. You can access MAP171D for line item detail information:
Reviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied Avoiding/Correcting This ErrorVerify 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:
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 ContentReviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied Avoiding/Correcting This ErrorVerify 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:
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 ContentReviewed: Apr 17, 2023 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. You can access MAP171D for line item detail information:
Reviewed: Apr 17, 2023 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorReview 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:
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 ContentReviewed: Apr 17, 2023 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorVerify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
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. Reviewed: Apr 17, 2023 |
39934 | All revenue lines denied and one or more of the lines denote beneficiary responsibility. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue lines denied and one or more of the lines denote beneficiary responsibility. Avoiding/Correcting This ErrorYou can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:
Reviewed: Apr 17, 2023 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorReview 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:
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 ContentReviewed: Apr 17, 2023 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorVerify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
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. Reviewed: Apr 17, 2023 |
39934 | All revenue lines denied and one or more of the lines denote beneficiary responsibility. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue lines denied and one or more of the lines denote beneficiary responsibility. Avoiding/Correcting This ErrorYou can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:
Reviewed: Apr 17, 2023 |
52MUE | All the line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an ABN. |
Denial |
Claim Error Reason Code 52MUEError Description
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 ErrorYou 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
Reviewed: Apr 17, 2023 |
52NCD | Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes. |
Denial |
Claim Error Reason Code 52NCDError Description
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 ErrorEnsure 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. Reviewed: Apr 17, 2023 |
53NCD | Line level denial to indicate that none of the diagnosis codes on the claim support medical necessity of the services. Service was denied beneficiary liable, because the modifier “GA” is present on the line or occurrence code 32 is present on the claim and modifier “GA” is not present on any claim line. |
Denial |
Claim Error Reason Code 53NCDError Description
Line level denial to indicate that none of the diagnosis codes on the claim support medical necessity of the services. Service was denied beneficiary liable, because the modifier “GA” is present on the line or occurrence code 32 is present on the claim and modifier “GA” is not present on any claim line. Avoiding/Correcting This ErrorReview coverage guidelines for the service being denied to ensure medical necessity of the services being provided to the beneficiary. Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. the diagnosis that are covered for the services provided. Related Content
Reviewed: Apr 17, 2023 |
54NCD | Line level reason code to indicate that none of the diagnosis codes on the claim support the medical necessity of the services. Service denied and the provider is liable. |
Denial |
Claim Error Reason Code 54NCDError Description
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 ErrorReview 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 ContentReviewed: Apr 17, 2023 |
55A07 | This claim/service was denied because the related or qualifying claim/service was not paid or identified on the claim. |
Denial |
Claim Error Reason Code 55A07Error Description
This claim/service was denied because the related or qualifying claim/service was not paid or identified on the claim. Avoiding/Correcting This ErrorMedicare does not cover medical and hospital services that are related to and required as a result of services that are not covered. Ensure that medical necessity requirements are met and well documented at the time of service. Submit all relevant medical records to Medical Review upon request. Related Content
Reviewed: Apr 17, 2023 |
55B00 | Ensure that complete medical records are submitted for each claim receiving an ADR. When applicable, ensure that the plan of treatment to support the need for services is included with the medical records submitted to NGS for review. Documentation should support an individualized plan of treatment was reviewed and signed by the physician at the applicable time frame prescribed by CMS. |
Denial |
Claim Error Reason Code 55B00Error Description
Ensure that complete medical records are submitted for each claim receiving an ADR. When applicable, ensure that the plan of treatment to support the need for services is included with the medical records submitted to NGS for review. Documentation should support an individualized plan of treatment was reviewed and signed by the physician at the applicable time frame prescribed by CMS. Avoiding/Correcting This ErrorAs appropriate, submit plan of treatment to support the need for services to the Appeals Department for review. Related ContentReviewed: Apr 17, 2023 |
55B00 | Ensure that complete medical records are submitted for each claim receiving an ADR. When applicable, ensure that the plan of treatment to support the need for services is included with the medical records submitted to NGS for review. Documentation should support an individualized plan of treatment was reviewed and signed by the physician at the applicable time frame prescribed by CMS. |
Denial |
Claim Error Reason Code 55B00Error Description
Ensure that complete medical records are submitted for each claim receiving an ADR. When applicable, ensure that the plan of treatment to support the need for services is included with the medical records submitted to NGS for review. Documentation should support an individualized plan of treatment was reviewed and signed by the physician at the applicable time frame prescribed by CMS. Avoiding/Correcting This ErrorAs appropriate, submit plan of treatment to support the need for services to the Appeals Department for review. Related ContentReviewed: Apr 17, 2023 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
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 ErrorReview 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:
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
Reviewed: Apr 17, 2023 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
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 ErrorReview 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:
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
Reviewed: Apr 17, 2023 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
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 ErrorReview 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:
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
Reviewed: Apr 17, 2023 |
56900 | This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. |
Denial |
Claim Error Reason Code 56900Error Description
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 ErrorRegularly 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 InformationThis 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. Reviewed: Apr 17, 2023 |
56900 | This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. |
Denial |
Claim Error Reason Code 56900Error Description
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 ErrorRegularly 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 InformationThis 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. Reviewed: Apr 17, 2023 |
59301 | This claim is denied for payment due to: This inpatient 11X claim did not include covered diagnoses and procedure code(s) as required per National Coverage Decision (NCD) 20.4 specific to “Implantable Cardioverter Defibrillators (ICDs).
|
Denial |
Claim Error Reason Code 59301Error Description
This claim is denied for payment due to: This inpatient 11X claim did not include covered diagnoses and procedure code(s) as required per National Coverage Decision (NCD) 20.4 specific to “Implantable Cardioverter Defibrillators (ICDs).
Avoiding/Correcting This ErrorTo prevent this error, ensure all Medicare coverage and medical necessity requirements are met prior to billing. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis and procedure codes that are covered for the services rendered. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Review the coverage and billing relevant to NCD 20.4 prior to rendering the services. 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
Reviewed: Apr 17, 2023 |
5WEXC | As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals. |
Denial |
Claim Error Reason Code 5WEXCError Description
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 ErrorEnsure 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. Reviewed: Apr 17, 2023 |
75999 | Home health claim contains invalid CBSA code or special wage index code corresponding to the state and county of the beneficiary’s place of residence in value code 61. |
RTP |
Claim Error Reason Code 75999Error Description
Home health claim contains invalid CBSA code or special wage index code corresponding to the state and county of the beneficiary’s place of residence in value code 61. Avoiding/Correcting This ErrorVerify the CBSA code reported on your RAP claim. For episodes that cross over 2015/2016, use the CBSA that is valid for 2015 on the RAP and then submit the 2016 CBSA on the final claim. CBSA codes can be found in the CY2016 Wage Index File on the CMS website. Reviewed: Apr 17, 2023 |
75999 | Home health claim contains invalid CBSA code or special wage index code corresponding to the state and county of the beneficiary’s place of residence in value code 61. |
RTP |
Claim Error Reason Code 75999Error Description
Home health claim contains invalid CBSA code or special wage index code corresponding to the state and county of the beneficiary’s place of residence in value code 61. Avoiding/Correcting This ErrorVerify the CBSA code reported on your RAP claim. For episodes that cross over 2015/2016, use the CBSA that is valid for 2015 on the RAP and then submit the 2016 CBSA on the final claim. CBSA codes can be found in the CY2016 Wage Index File on the CMS website. Reviewed: Apr 17, 2023 |
7A000 | The reason for this claim returning to you for correction is available on Claim page 4 in the Remarks area |
RTP |
Claim Error Reason Code 7A000Error Description
The reason for this claim returning to you for correction is available on Claim page 4 in the Remarks area Avoiding/Correcting This ErrorReview the narrative in the Remarks on claim page 4 and make any necessary corrections then return the claim to your intermediary. Reviewed: Apr 17, 2023 |
7C387 | An unacceptable principle diagnosis code was billed on this claim. |
Denial |
Claim Error Reason Code 7C387Error Description
An unacceptable principle diagnosis code was billed on this claim. Avoiding/Correcting This ErrorThe unacceptable principle diagnosis for this denial is typically related to dental services. If additional medical circumstances exist or a more specific medical reason exists, submit an appeal and include medical documentation to support the denied services. This should include a medical history, physical exam, result of pertinent diagnostic tests, doctor’s orders or any other documentation to support this change. Related Content
Reviewed: Apr 17, 2023 |
7C387 | Unacceptable ICD-10 principle diagnosis code for dental services. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal. Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. |
Denial |
Claim Error Reason Code 7C387Error Description
Unacceptable ICD-10 principle diagnosis code for dental services. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal. Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. Avoiding/Correcting This ErrorDenial for dental services related to coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment. Related ContentCMS MLN Matters Publication Items and Services Not Covered Under Medicare Reviewed: Apr 17, 2023 |
7C387 | Claim does not qualify for Medicare; the principal diagnosis code is for dental services. Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. |
Denial |
Claim Error Reason Code 7C387Error Description
Claim does not qualify for Medicare; the principal diagnosis code is for dental services. Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. Avoiding/Correcting This ErrorIf additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim on appeal. Related Content
Reviewed: Apr 17, 2023 |
7C625 | Clarify reason for discharge. |
RTP |
Claim Error Reason Code 7C625Error Description
Clarify reason for discharge. Avoiding/Correcting This ErrorRemarks are required when a beneficiary is discharged or revokes the hospice benefit. Note: If the beneficiary transferred to a VA hospital, a transfer is not valid. The beneficiary must revoke or be discharged. Note: If the beneficiary is deceased, correct the patient status code. Patient status code 01 is invalid in this situation. Related ContentReviewed: Apr 17, 2023 |
7ECBS | Home health claims cannot be billed with the 5XXXX CBSA range of codes beginning with statement through date 1/1/2016 through 12/31/2016. |
RTP |
Claim Error Reason Code 7ECBSError Description
Home health claims cannot be billed with the 5XXXX CBSA range of codes beginning with statement through date 1/1/2016 through 12/31/2016. Avoiding/Correcting This ErrorVerify the CBSA code reported on your RAP claim. CBSA codes can be found in the HH PPS Wage Index File on the CMS website. Reviewed: Apr 17, 2023 |
7K073 | This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. |
Rejection |
Claim Error Reason Code 7K073Error Description
This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. Avoiding/Correcting This ErrorIf the beneficiary is entitled to Medicare Part B, an ancillary claim may be submitted to your MAC. Related ContentReviewed: Apr 17, 2023 |
7MSPG | Claim billed with value code 12 or 43 but contains conflicting information when billing secondary or conditionally, or information conflicts with CWF group health plan records.
When the beneficiary has dual entitlement under the working aged (65 and older) or disability (64 and under) provision and under the ESRD provision, ESRD remains as the primary payer until the end of the coordination period. There cannot be working aged or disability records open during a valid ESRD coordination period. If CWF indicates a valid ESRD coordination period for the claim dates of service, the claims cannot be submitted with value code 12 or 43. An ESRD beneficiary can only become working aged and/or disability after the completion of a COB or if their ESRD based eligibility or entitlement ceases prior to the end of the 30 month coordination period. (e.g. 12 months after maintenance dialysis treatments are no longer required or 36 months after a successful transplant) and all other provisional requirements are met, otherwise Medicare becomes primary at the end of the ESRD COB and remains primary. The claim is billed with one or more of these condition codes: 09, 10 or 11; or condition code 28 is present with value code 12; or condition code 29 is present with value code 43. The claim is billed with one or more of these occurrence codes: 18 or 19.
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RTP |
Claim Error Reason Code 7MSPGError Description
Claim billed with value code 12 or 43 but contains conflicting information when billing secondary or conditionally, or information conflicts with CWF group health plan records.
When the beneficiary has dual entitlement under the working aged (65 and older) or disability (64 and under) provision and under the ESRD provision, ESRD remains as the primary payer until the end of the coordination period. There cannot be working aged or disability records open during a valid ESRD coordination period. If CWF indicates a valid ESRD coordination period for the claim dates of service, the claims cannot be submitted with value code 12 or 43. An ESRD beneficiary can only become working aged and/or disability after the completion of a COB or if their ESRD based eligibility or entitlement ceases prior to the end of the 30 month coordination period. (e.g. 12 months after maintenance dialysis treatments are no longer required or 36 months after a successful transplant) and all other provisional requirements are met, otherwise Medicare becomes primary at the end of the ESRD COB and remains primary. The claim is billed with one or more of these condition codes: 09, 10 or 11; or condition code 28 is present with value code 12; or condition code 29 is present with value code 43. The claim is billed with one or more of these occurrence codes: 18 or 19.
Avoiding/Correcting This Error
Reviewed: Apr 17, 2023 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorIf services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient). Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex. If appropriate, make corrections and resubmit a new claim. Reviewed: Apr 17, 2023 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorIf 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. Reviewed: Apr 17, 2023 |
C7010 | An inpatient, outpatient, or home health claim has service dates overlapping a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
An inpatient, outpatient, or home health claim has service dates overlapping a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorCheck HIQA for an open hospice period and verify if the hospice dates overlap the dates of service billed on your claim. Any services not related to hospice care can be billed with condition code 07. Reviewed: Apr 17, 2023 |
C7010 | An inpatient, outpatient, or home health claim for a patient who elected the Medicare hospice benefit and the claim does not contain a condition code 07 (zero 7). Hospice coverage replaces Medicare for services related to terminal diagnosis. |
Rejection |
Claim Error Reason Code C7010Error Description
An inpatient, outpatient, or home health claim for a patient who elected the Medicare hospice benefit and the claim does not contain a condition code 07 (zero 7). Hospice coverage replaces Medicare for services related to terminal diagnosis. Avoiding/Correcting This ErrorUse CWF to identify hospice beneficiary (information also available in IVR, NGSConnex). View dates indicating election period. Review revocation indicator:
If claim’s DOS fall within hospice election period, determine whether services are related to terminal illness.
Reviewed: Apr 17, 2023 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorVerify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex. If services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient). If services are related, submit the claim to the hospice agency. Reviewed: Apr 17, 2023 |
C7080 | The dates of service on this outpatient claim fall within or overlap the ‘from’ and ‘through’ dates on an inpatient claim from another provider. |
Rejection |
Claim Error Reason Code C7080Error Description
The dates of service on this outpatient claim fall within or overlap the ‘from’ and ‘through’ dates on an inpatient claim from another provider. Avoiding/Correcting This Error
Reviewed: Apr 17, 2023 |
C7080 | The dates of service on this outpatient claim fall within or overlap the ‘from’ and ‘through’ dates on an inpatient claim from another provider. |
Rejection |
Claim Error Reason Code C7080Error Description
The dates of service on this outpatient claim fall within or overlap the ‘from’ and ‘through’ dates on an inpatient claim from another provider. Avoiding/Correcting This Error
Reviewed: Apr 17, 2023 |
CO-109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
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ANSI |
Claim Error Reason Code CO-109Error Description
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Avoiding/Correcting This ErrorMany times Medicare beneficiaries are enrolled in an MA plan, instead of “traditional fee-for-service” Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans,” are health plans offered by private companies approved by Medicare. Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan. During patient registration, it is also important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. This information helps determine who to bill and how to file claims with Medicare. During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by another contractor. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information. Reviewed: Apr 19, 2023 |
CO-109 | Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. |
ANSI |
Claim Error Reason Code CO-109Error Description
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. Avoiding/Correcting This ErrorMany times Medicare beneficiaries are enrolled in an MA plan, instead of “traditional fee-for-service” Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans,” are health plans offered by private companies approved by Medicare. Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan. During patient registration, it is also important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. This information helps determine who to bill and how to file claims with Medicare. During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by another contractor. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information. Reviewed: Apr 19, 2023 |
CO-16 | Claim/service lacks information or has submission/billing error(s). N382: |
ANSI |
Claim Error Reason Code CO-16Error Description
Claim/service lacks information or has submission/billing error(s). N382: Avoiding/Correcting This ErrorIn 2020, CMS removed the SSN-based identifier from the Medicare card to protect beneficiaries and offer better identity protection. The MBI is the patient identification number assigned to Medicare beneficiaries. Claims submitted to Medicare contractors must contain the MBI. Visit CMS’ MBI web page for detailed information
Make the appropriate correction to the claim and resubmit. Note: If you have entered the MBI exactly how it appears on the Medicare ID card and the patient advises that it’s the most recent copy they have, then the patient would need to contact Social Security to verify/obtain the correct information. Reviewed: Apr 18, 2023 |
CO-22 | This care may be covered by another payer per coordination of benefits. |
ANSI |
Claim Error Reason Code CO-22Error Description
This care may be covered by another payer per coordination of benefits. Avoiding/Correcting This ErrorDuring patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer. Reviewed: Apr 17, 2023 |
N5052 | The spelling of the beneficiary’s name or the beneficiary’s MBI on the claim differs from the information in the beneficiary’s master file. |
RTP |
Claim Error Reason Code N5052Error Description
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 ErrorThe 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
Reviewed: Apr 17, 2023 |
N5052 | The CMS CWF indicates the beneficiary’s name and MBI do not match. |
RTP |
Claim Error Reason Code N5052Error Description
The CMS CWF indicates the beneficiary’s name and MBI do not match. Avoiding/Correcting This ErrorVerify the information and submit a new claim with the correct information. Check CWF (HIQA) for a logically deleted MBI and resubmit with the correct number, if applicable. Reviewed: Apr 17, 2023 |
OA-109 | Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor. |
ANSI |
Claim Error Reason Code OA-109Error Description
Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor. Avoiding/Correcting This ErrorMany times Medicare beneficiaries are enrolled in an MA plan, instead of “traditional fee-for-service” Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans,” are health plans offered by private companies approved by Medicare. Our self-service tools (NGSConnex/IVR) provide patient eligibility and benefit information (including MA information) to assist in determining if your patient is enrolled in a MA plan. During patient registration, it is also important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. This information helps determine who to bill and how to file claims with Medicare. During patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by another contractor. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information. Reviewed: Apr 19, 2023 |
OA-18 | Exact duplicate claim/service. |
ANSI |
Claim Error Reason Code OA-18Error Description
Exact duplicate claim/service. Avoiding/Correcting This ErrorA 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:
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:
Remittance Advice Tips:
Reviewed: Apr 17, 2023 |
PR-31 | Patient cannot be identified as our insured. |
ANSI |
Claim Error Reason Code PR-31Error Description
Patient cannot be identified as our insured. Avoiding/Correcting This ErrorServices were denied for one or more of the following reasons:
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:
Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information. Reviewed: Apr 17, 2023 |
T5052 | CMS’ records indicate the beneficiary is not in file. |
RTP |
Claim Error Reason Code T5052Error Description
CMS’ records indicate the beneficiary is not in file. Avoiding/Correcting This ErrorVerify the beneficiary’s identification and resubmit this claim. Reviewed: Apr 17, 2023 |
U5106 | Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period. |
RTP |
Claim Error Reason Code U5106Error Description
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 ErrorWhen the hospice NOE was received it fell within a previously established election period.
Reviewed: Apr 17, 2023 |
U5111 | Hospice NOE received for revocation (8XB) or void of election period (8XD) and the start date on the transaction falls within a previously established hospice election period on the hospice master record for this beneficiary. |
RTP |
Claim Error Reason Code U5111Error Description
Hospice NOE received for revocation (8XB) or void of election period (8XD) and the start date on the transaction falls within a previously established hospice election period on the hospice master record for this beneficiary. Avoiding/Correcting This ErrorVerify the transaction is billed with the correct dates. If the CWF doesn’t show the updated election period information, wait for any applicable claims to process before resubmitting. Reviewed: Apr 17, 2023 |
U5165 | The dates of service on this claim fall between two hospice election periods on CWF and have been billed out of sequence; therefore, this claim is unable to process. |
RTP |
Claim Error Reason Code U5165Error Description
The dates of service on this claim fall between two hospice election periods on CWF and have been billed out of sequence; therefore, this claim is unable to process. Avoiding/Correcting This ErrorEither an election period has posted or claims have posted which caused previous claims to not process, and is now causing an overlap at CWF. In order for the previous claims to process, any claim(s) that have been submitted in the 'next' overlapping election period will have to be cancelled. Once all of the cancels have finalized, you must submit an 8XD type of bill to void the election period. After all of the above has been completed, resubmit the claim(s) with dates that fell in between the two election periods for sequential processing. These must be submitted in sequential order for all claims to post correctly in the election periods. Reviewed: Apr 17, 2023 |
U5166 | Hospice claim received and the ‘From’ date falls within an established hospice election period and the start “2” date is equal to zeros (no change of ownership or provider change has occurred). The provider number on this claim is not equal to provider “1” on established hospice election period. |
RTP |
Claim Error Reason Code U5166Error Description
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
Reviewed: Apr 17, 2023 |
U5181 | Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3, occurrence code 27 is reported on the claim for the billing period in which the certification or recertification was obtained. Therefore:
|
RTP |
Claim Error Reason Code U5181Error Description
Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3, occurrence code 27 is reported on the claim for the billing period in which the certification or recertification was obtained. Therefore:
Avoiding/Correcting This ErrorEnsure the usage of an appropriate certification or recertification date in accordance with occurrence code 27. Related ContentReviewed: Apr 17, 2023 |
U5194 | A hospice NOE with an admission date on or after 10/1/2014 must be received within five calendar days after the effective date of the hospice election. An initial hospice claim (where the from date matches the admit date) has been received where the NOE was not received timely and OSC 77 is either missing or contains invalid dates. |
RTP |
Claim Error Reason Code U5194Error Description
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 ErrorIn 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 ContentReviewed: Apr 17, 2023 |
U5194 | 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 the occurrence span code 77 is either missing or contains invalid dates. |
RTP |
Claim Error Reason Code U5194Error Description
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 the occurrence span code 77 is either missing or contains invalid dates. Avoiding/Correcting This ErrorIn 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 ContentReviewed: Apr 17, 2023 |
U5200 | CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
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 ErrorPart of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system or the FISS/DDE Provider Online System or NGSConnex to verify beneficiary eligibility prior to claim submission. Related ContentReviewed: Apr 17, 2023 |
U5200 | Inpatient services are reported on the claim and the beneficiary’s Part A coverage is not in effect; or outpatient services are reported on the claim and the beneficiary’s Part B coverage is not in effect. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
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 ErrorPart 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. Reviewed: Apr 17, 2023 |
U5200 | CMS' records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
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 ErrorPart of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS DDE Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission. Reviewed: Apr 17, 2023 |
U5210 | The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This Error Verify that the MBI on the claim is for the correct beneficiary.
Reviewed: Apr 17, 2023 |
U5210 | The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorCheck the beneficiary’s entitlement dates. Your claim from and through dates may only encompass dates during which the beneficiary was entitled to Medicare. Reviewed: Apr 17, 2023 |
U5210 | Services are provided prior to a beneficiary’s Medicare Part A or Part B entitlement date, Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
Services are provided prior to a beneficiary’s Medicare Part A or Part B entitlement date, Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorPart of the eligibility verification process should include ensuring the DOS 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. Reviewed: Apr 17, 2023 |
U5210 | The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorVerify that the MBI on the claim is for the correct beneficiary.
Reviewed: Apr 17, 2023 |
U5210 | The beneficiary's entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary's entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorVerify that the MBI on the claim is for the correct beneficiary.
Reviewed: Apr 17, 2023 |
U5211 | Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. |
Rejection |
Claim Error Reason Code U5211Error Description
Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. Avoiding/Correcting This ErrorVerify the Medicare number and dates of service billed on your claim.
Reviewed: Apr 17, 2023 |
U5211 | The statement from/through date is greater than the date of death on the beneficiary master record. |
Rejection |
Claim Error Reason Code U5211Error Description
The statement from/through date is greater than the date of death on the beneficiary master record. Avoiding/Correcting This ErrorVerify the MBI and dates of service.
Reviewed: Apr 17, 2023 |
U5211 | Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. |
Rejection |
Claim Error Reason Code U5211Error Description
Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. Avoiding/Correcting This ErrorVerify the Medicare number and dates of service billed on your claim:
Reviewed: Apr 17, 2023 |
U5211 | Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. |
Rejection |
Claim Error Reason Code U5211Error Description
Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death. Avoiding/Correcting This ErrorVerify the Medicare number and dates of service billed on your claim.
Reviewed: Apr 17, 2023 |
U5220 | The services billed on the claim were provided prior to the date the beneficiary was entitled to Medicare coverage. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5220Error Description
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 ErrorVerify 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. Reviewed: Apr 17, 2023 |
U5220 | The services billed on the claim were provided prior to the date the beneficiary was entitled to Medicare coverage. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5220Error Description
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 ErrorVerify 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. Reviewed: Apr 17, 2023 |