Top Claim Errors
Reason Code Description Error Type Details
CO-16

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

MA112:
Missing/incomplete/invalid group practice information.

ANSI
CO-16

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

MA112:
Missing/incomplete/invalid group practice information.

ANSI
CO-16

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

N382:
Missing/incomplete/invalid procedure code(s).

ANSI
CO-16

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

N822:
Missing procedure modifiers(s).

ANSI
CO-16

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

N822:
Missing procedure modifiers(s).

ANSI
CO-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
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
CO/PR-29

The time limit for filing has expired.
N211: Alert: You may not appeal this decision.

ANSI
CO/PR-29

The time limit for filing has expired.
N211: Alert: You may not appeal this decision.

ANSI
OA-109

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

 

ANSI
OA-18

Exact duplicate claim/service.

ANSI
PR-31

Patient cannot be identified as our insured.

ANSI
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
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
12302

The sum of covered and noncovered days must equal the total number of days in the statement covers period.                                             

RTP
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
19508

An invalid ICD-9 or ICD-10 diagnosis code is submitted on the claim.

RTP
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
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
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
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
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
31094

When the TOB frequency on the claim = 0, the total covered charges on the claim cannot be greater than zero.

RTP
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
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
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
31323

Condition code 20 is present and the claim contains covered charges.

RTP
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
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
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
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:

  • If the admission date of the claim is equal to the statement from date
  • The 0023 line date should also be equal or revenue code 0023 was not found
  • If a final claim, the 0023 service date must equal a visit service date
RTP
31788

Noncovered charges do not match between claim page 03 and 32.

RTP
31836

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

RTP
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
32078

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

  1. TOB IS 71X, Provider range 3400‒3499, 3800‒3999, 8500‒8899
    (FACILITY TYPE = M) OR 8900‒8999 (FACILITY TYPE =S) and revenue code other than 521, 522, 900 or 780 with line item DOS on or after 4/1/2005 is billed.
  2. TOB IS 71X, Provider range 3400‒3499, 3800‒3999, 85008899
    (FACILITY TYPE = M) OR 8900-8999 (FACILITY TYPE = S) and revenue code other than 521, 522, 524, 525, 527, 528, 780 or 900 with line item DOS on or after 7/1/2006 is billed.;
  3. TOB IS 73X, Provider range 1800‒1899 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item DOS on or after  4/1/2005 and prior to 4/1/2010 is billed.
  4. TOB IS 73X, Provider range 1000‒1199 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item  DOS on or after 4/1/2005 and prior to 4/10/2010 is billed.
  5. Revenue codes 520, 521, 522, 780 and  900 can only be billed with one unit per revenue code line for dates of service on or after 4/1/2005.
  6. TOB IS 71X, 73X OR 77X and there is no line item DOS on a line.
  7. TOB IS 77X, Provider range 1000‒1199 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 OR 900 with line item  DOS on or after 4/1/2010.
  8. TOB IS 77X, Provider range 1800‒1989 (FACILITY TYPE = S OR M) and revenue code is other than 520, 780 or 900 with line item DOS on or after 4/1/2010.

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

RTP
32078

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

  • There is no line item DOS on a line.
  • Provider number (PTAN) range is XX1000‒XX1199 (FACILITY TYPE = S OR M) and revenue code is other than 52X, 78X OR 900.
  • Provider number (PTAN) range is XX1800‒XX1989 (FACILITY TYPE = S OR M) and revenue code is other than 52X, 78X or 900.
RTP
32103

NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file.

RTP
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
32103

NPI/OSCAR number pair on the claim is not present in the Medicare NPI crosswalk file.

RTP
32242

The revenue code billed is non- billable for this type of bill and covered charges are great than zero.

RTP
32242

The revenue code is non-billable for this type of bill and covered charges are greater than zero.

RTP
32243

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

RTP
32266

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

RTP
32287

A non-roster claim was submitted and contains more than one PPV or flu vaccine or administration on the same DOS.

RTP
32358

Claim submitted after the revocation date on the provider file with the following criteria:

  • PECOS status indicator of 11 on MAP 1102 and MAP1103
  • Receipt date of the claim is on or after day 61 of a provider’s revocation, even if the date of service is prior to the revocation date. 
Rejection
32400

A HCPCS code is required for a revenue code reported on this claim; however, the HCPCS code is missing.

RTP
32402

The HCPCS code(s) reported on this claim have not been billed with a valid revenue code for the dates of service.

RTP
32402

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

RTP
32402

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

RTP
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
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
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
32404

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

  1. The HCPCS code entered on the claim is not a valid HCPCS/CPT code.
  2. The HCPCS code entered on the claim is not billable to Medicare.
RTP
32405

The 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
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
32415

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

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

or

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

  • Effective for dates of service 10/1/2010 and greater, HCPCS 90662 and  90670 are added to the list of codes.
  • Effective for dates of service 5/9/2011 and greater, HCPCS 90654 was added to the list of codes.
  • Effective for dates of service 7/1/2012 and greater, HCPCS Q2034 was added to the list of codes.
  • Effective for dates of service 11/20/2012 and greater, HCPCS 90661 was added to the list of codes.
  • Effective for dates of service 1/01/2013 and greater, HCPCS 90653, 90672, 90685–90688 and Q2033 was added to the list of codes.
  • Effective for dates of service 1/1/2014 and greater, HCPCS 90673 was added to the list of codes.
RTP
32415

Condition code 'A6' is required when a vaccine HCPCS code is present on the claim. 

RTP
32415

Condition code ‘A6’ is required when one or more of the following HCPCS/CPT codes are present on the claim:
90655–90660, 90724, 90732, G0008, G0009, G9141, Q2035–Q2039, 90662, 90670, 90654, Q2034, 90661, 90653, 90672, 90685–90688, Q2033, 90673

 

RTP
32511

NDC information is missing or present on the claim but is missing one of the required elements NDC, quantity qualifier or quantity.

RTP
32511

NDC information is missing or present on the claim but is missing one of the required elements (NDC, quantity qualifier or quantity).

RTP
32710

One or more diagnosis codes are equal.

RTP
32959

The provider type and bill type are an invalid combination.

  • Free Standing FQHCs (PTAN XX1000–XX1199) and provider-based facilities (PTAN XX1800–XX1989) must submit claims on the 77X claim type.
RTP
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
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
34281

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

Rejection
34281

Claim submitted as Medicare Primary and a positive working elderly record exists at CWF.

Rejection
34293

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

Rejection
34295

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

Rejection
34538

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

Rejection
34538

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

Rejection
34538

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

Rejection
34538

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

Rejection
34538

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

Rejection
34538

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

Rejection
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
34540

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

Rejection
34540

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

Rejection
34540

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

Rejection
34540

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

Rejection
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
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
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
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
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
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
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
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
37098

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

RTP
38031

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

  • Statement from and through dates overlap
  • Provider numbers are the same
  • At least one revenue code line matches
  • Diagnosis code(s) on the history and incoming claim are the same
  • For TOB 77X FQHC claims, the diagnosis codes are the same or different
  • For TOB 77X FQHC claims, the HCPCS code matches but different revenue codes
  • If the history or incoming claim has one of the following HCPCS code modifiers [LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9] for the same HCPCS code and same DOS and ‒ the incoming or history claim has a blank HCPCS code modifier ‒ or ‒ the HCPCS code modifier is not LT, RT, E1‒E4, FA, F1‒F9, TA OR T1‒9, at least one HCPCS code is the same on both claims (for 77X FQHC claims, blank HCPCS code is a match)
  • THE HCPCS code/modifier [LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9] are equal on the incoming and history claim.
  • TOB 71X history and incoming claim have the same diagnosis, for the same beneficiary, DOS and provider, even if the revenue code line that matches the history claim is missing the line level DOS or HCPCS code on either the incoming or history claim.
  • This reason code will assign when modifiers billed on the line are not equal (excluding special logic for modifiers listed above) and editing is performed at the HCPC level.
Rejection
38031

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

  • Statement from and through dates overlap
  • Provider numbers are the same
  • At least one revenue code line matches
  • Diagnosis code(s) on the history and incoming claim are the same
  • For TOB 77X FQHC claims, the diagnosis codes are the same or different
  • For TOB 77X FQHC claims, the HCPCS code matches but different revenue codes
  • If the history or incoming claim has one of the following HCPCS code modifiers [LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9] for the same HCPCS code and same DOS and ‒ the incoming or history claim has a blank HCPCS code modifier ‒ or ‒ the HCPCS code modifier is not LT, RT, E1‒E4, FA, F1‒F9, TA OR T1‒9, at least one HCPCS code is the same on both claims (for 77X FQHC claims, blank HCPCS code is a match)
  • THE HCPCS code/modifier [LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9] are equal on the incoming and history claim.
  • TOB 71X history and incoming claim have the same diagnosis, for the same beneficiary, DOS and provider, even if the revenue code line that matches the history claim is missing the line level DOS or HCPCS code on either the incoming or history claim.
  • This reason code will assign when modifiers billed on the line are not equal (excluding special logic for modifiers listed above) and editing is performed at the HCPC level.
Rejection
38031

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

  1. Statement ‘from’ and ‘through’ dates overlap
  2. Provider numbers are the same
  3. At least one revenue code line matches
  4. The diagnosis code(s) on both the history and incoming claim are the same
  5. If the history or incoming claim has one of the following HCPCS modifiers LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9 for the same HCPCS, and same date of service, and the incoming or history claim has a blank HCPCS modifier, or the HCPCS modifier isn’t equal to LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9
  6. At least one HCPCS code is the same on both claims or
  7. If HCPCS modifier (LT, RT, E1‒E4, FA, F1‒F9, TA or T1‒T9) are equal on both the incoming and history claim, the reason code will assign
Rejection
38032

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

Rejection
38032

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

  1. The ‘statement covers period’ is the same on both bills
  2. Provider numbers are the same
  3. At least one revenue code or one HCPCS code is the same on both bills
  4. At least one diagnosis code matches on both claims and
  5. At least one line item date of service for lab charges is the same on both claims
Rejection
38032

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

Rejection
38032

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

  1. The ‘statement covers period’ is the same on both bills
  2. Provider numbers are the same
  3. At least one revenue code or one HCPCS code is the same on both bills
  4. At least one diagnosis code matches on both claims and
  5. At least one line item date of service for lab charges is the same on both claims
Rejection
38037

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
38038

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

RTP
38050

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

  • MBI
  • Provider number
  • Statement ‘from’ date of service
  • Statement ‘thru’ date of service
  • Revenue code
  • HCPCS and modifiers (if required by Revenue Code File)
Rejection
38050

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

  • MBI
  • Provider number
  • Statement ‘from’ date of service
  • Statement ‘thru’ date of service
  • Revenue code
  • HCPCS and modifiers (if required by Revenue Code File)
Rejection
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
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
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
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
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
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
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
38119

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

RTP
38119

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

RTP
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
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
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
38200

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

  • MBI number
  • Type of bill (all three positions of any TOB)
  • Provider number
  • Statement from date of service
  • Statement through date of service
  • Total charges (0001 revenue line)
  • Revenue code
  • HCPCS and modifiers (if required by revenue code file)
Rejection
38200

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

  • MBI
  • TOB (all three positions of any TOB)
  • Provider number
  • Statement ‘from’ date of service
  • Statement ‘through’ date of service
  • Total charges (0001 revenue line)
  • Revenue code
  • HCPCS and modifiers (if required by revenue code file)
Rejection
38200

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

  • MBI
  • TOB (all three positions of any TOB)
  • Provider number
  • Statement ‘'from’ date of service
  • Statement ‘through’ date of service
  • Total charges (0001 revenue line)
  • Revenue code
  • HCPCS and modifiers (if required by revenue code file)
Rejection
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
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
38312

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

  • MBI
  • Provider number
  • LIDOS

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

Rejection
38312

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

Rejection
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
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
39721

The requested nonmedical information was not received timely.

Rejection
39721

The requested nonmedical information was not received timely. 

Rejection
39721

The requested nonmedical information was not received timely. 

Rejection
39928

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

Denial
39928

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

Denial
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39929

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
39934

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

Rejection
52MUE

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

Denial
52NCD

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

Denial
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
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
55A07

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

Denial
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
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
55B31

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

Denial
55B31

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

Denial
55B31

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

Denial
56900

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

Denial
56900

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
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
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
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
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
7A000

The reason for this claim returning to you for correction is available on Claim page 4 in the Remarks area

RTP
7C387

An unacceptable principle diagnosis code was billed on this claim.

Denial
7C387

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

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

Denial
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
7C625

Clarify reason for discharge.

RTP
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
7K073

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

Rejection
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. 

  • Value Code 12 - Medicare can only be secondary when the beneficiary is age 65 or older at time of service and either the beneficiary or spouse is actively employed with an employer of 20 or more full and/or part-time employees.
  • Value Code 43 - Medicare can only be secondary when the beneficiary is 64 or under at time of service, on Medicare because of (non-ESRD) disability and either the beneficiary or other family member is actively employed with an employer of 100 or more full and/or part-time employees.

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.

  • If occurrence code is 18 then the patient relationship code cannot be 01.
  • If occurrence code is 19 then the patient relationship code cannot be 02.
  • If occurrence code 25 – date benefits terminated by primary payer is prior to the DOS on this claim – if date is correct then Medicare should be primary.
RTP
C7010

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

Rejection
C7010

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

Rejection
C7010

An inpatient, outpatient, or home health claim has service dates overlapping a hospice election period and condition code 07 is not present.

Rejection
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
C7010

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

Rejection
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
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
CO-109

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

 

ANSI
CO-109

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

ANSI
CO-16

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

N382:
Missing/incomplete/invalid procedure code(s).

ANSI
CO-22

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

ANSI
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
N5052

The CMS CWF indicates the beneficiary’s name and MBI do not match.

RTP
OA-109

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

ANSI
OA-18

Exact duplicate claim/service.

ANSI
PR-31

Patient cannot be identified as our insured.

ANSI
T5052

CMS’ records indicate the beneficiary is not in file.

RTP
U5106

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

RTP
U5111

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

RTP
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
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
U5181

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

  • If the certification/recertification was done prior to the service dates on the claim, an occurrence code 27 is not appropriate
    or
  • When the claim dates of service are spanning a current election period, the occurrence code 27 date must equal the start date of the next election period. (Note that the occurrence code 27 date will create the next election period if one is not currently present.)
    or
  • If billing an occurrence code 27 date for a late recertification, an occurrence span code 77 must also be present for the days that are prior to the late recertification date.
RTP
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
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
U5200

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

Rejection
U5200

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

Rejection
U5200

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

Rejection
U5210

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

Rejection
U5210

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

Rejection
U5210

Services are provided prior to a beneficiary’s Medicare Part A or Part B entitlement date, Therefore, no Medicare payment can be made.

Rejection
U5210

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

Rejection
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
U5211

Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death.

Rejection
U5211

The statement from/through date is greater than the date of death on the beneficiary master record.

Rejection
U5211

Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death.

Rejection
U5211

Our records indicate that the services billed on the claim were provided after the beneficiary’s date of death.

Rejection
U5220

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

Rejection
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