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

MA112:
Missing/incomplete/invalid group practice information.

Avoiding/Correcting This Error

The 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:

• Items 33 -33b on the CMS-1500 claim form, or its electronic equivalent
• Item 33 - Enter the provider of service/supplier’s billing name, address, ZIP code and telephone number
  • This is a required field
• Item 33a – Enter the NPI of the billing provider or group
  • For a provider who is not a member of a group practice (e.g. private practice), enter the NPI of the individual physician/practitioner.
• Item 33b– Leave Item blank

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

MA112:
Missing/incomplete/invalid group practice information.

Avoiding/Correcting This Error

The 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:

• Items 33 -33b on the CMS-1500 claim form, or its electronic equivalent
• Item 33 - Enter the provider of service/supplier’s billing name, address, ZIP code and telephone number
  • This is a required field
• Item 33a – Enter the NPI of the billing provider or group
  • For a provider who is not a member of a group practice (e.g. private practice), enter the NPI of the individual physician/practitioner.
• Item 33b– Leave Item blank

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

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

Avoiding/Correcting This Error

In 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
Verify the following:

• The patients Medicare ID card to ensure the correct format was entered
• Contact the patient to ensure you have the most updated copy of the card

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.

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

N822:
Missing procedure modifiers(s).

Avoiding/Correcting This Error

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

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

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

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

N822:
Missing procedure modifiers(s).

Avoiding/Correcting This Error

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

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

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

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 Error

National 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.

Who are the MACs?          

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 Error

National 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.

Who are the MACs?          

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

Many 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.

Exact duplicate claim/service.

Avoiding/Correcting This Error

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

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

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

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

Electronic Claim Submitter Tips:

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

Remittance Advice Tips:

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

Patient cannot be identified as our insured.

Avoiding/Correcting This Error

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

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

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

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

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

Verify 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'.

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 Error

Add the missing information to the claim and F9 or resubmit.

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

Avoiding/Correcting This Error

Verify 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.

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 Error

Check 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:

• Position  1 and 2 = numeric
• Position  3 and 4 = alpha
• Position  5 and 6 = numeric
• Position  7 and 8 = alpha
• Position  9 = numeric
• Position  10 = 1 or 2
• Position  11-18 = alpha

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.

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 Error

Correct the diagnosis code and resubmit.

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 Content

• CMS MLN Matters Article SE18006: New Medicare Beneficiary Identifier (MBI) Get It, Use, It
• CMS website: Getting MBIs

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.

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 Error

Verify the type of bill and/or the total covered charges reported and if appropriate, correct. 

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

Avoiding/Correcting This Error

Verify 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.

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 Error

Hospices 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

• More information on sequential billing can be found in the Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 90. (200 KB)

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 Error

Report one of the following Valid Payer Codes on all MSP claims:

A = working aged – EGHP
B = End Stage Renal – EGHP
C = Conditional (any MSP value code $0.00 is required)
D = Med Pay/ No fault ins.
E = Workers compensation
F = PHS
G = Disability – LGHP
H = Black lung
L = Liability
Z = Medicare primary (no MSP value code)

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 Error

Report one of the following Valid Payer Codes on all MSP claims:
A = working aged – EGHP
B = End Stage Renal – EGHP
C = Conditional (any MSP value code $0.00 is required)
D = Med Pay/ No fault ins.
E = Workers compensation
F = PHS
G = Disability – LGHP
H = Black lung
L = Liability
Z = Medicare primary (no MSP value code)

Related Content

• Prepare and Submit an MSP Claim​​​​​​

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

Avoiding/Correcting This Error

Submit 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.

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 Error

Ensure 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

Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 3:

• Section 20.3 - Additional Payment Amounts for Hospitals with Disproportionate Share of Low-Income Patients
• Section 20.8 - Payment to Hospitals and Units Excluded from IPPS for Direct Graduate Medical Education (DGME) and Nursing and Allied Health (N&AH) Education for Medicare Advantage (MA) Enrollees

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 Error

When 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.

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 Error

When 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.

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

Avoiding/Correcting This Error

• Verify the admission date and ‘from’ date on the RAP and claim match.
• Verify the date on the 0023 revenue line for the RAP and claim match.
• Verify at least one revenue line on your final claim has a date of service that matches the date on the 0023 revenue line.

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

Avoiding/Correcting This Error

Verify billing and if appropriate, correct.

Note: if the original line was noncovered and you want to make covered, delete and rekey the line.

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

Avoiding/Correcting This Error

Change TOB to 85X.

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 Error

Verify 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).

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

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

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

Avoiding/Correcting This Error

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

Verify billing and if appropriate, correct.

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

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

Avoiding/Correcting This Error

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

Verify billing and if appropriate, correct.

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

Avoiding/Correcting This Error

This 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.

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 Error

This 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.

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

Avoiding/Correcting This Error

This 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.

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

Avoiding/Correcting This Error

Check 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.

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

Avoiding/Correcting This Error

To 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.

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

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

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

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

Avoiding/Correcting This Error

Use claim correction option to update claim, if appropriate.

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

• Additional information on the PPV and flu vaccine refer to the CMS MLN Educational Tool “Medicare Preventive Services”

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. 

Avoiding/Correcting This Error

If appropriate, make corrections and submit a new claim.

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

Avoiding/Correcting This Error

When 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.

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 Error

When reporting revenue code 0250 (noninjectable prescription drugs), a HCPCS code is not reported. Instead, this revenue code is reported with the NDC.

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

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 Error

Verify that HCPCS code is valid for the DOS in question prior to billing.

Related Content

• The NGS FISS DDE Provider Online Guide includes how to use the HCPCS Inquiry within the FISS DDE system to check for valid HCPCS codes. Refer to Chapter IV – Inquiries Submenu for details on how to use this function

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 Error

Verify that HCPCS code is valid for the DOS in question prior to billing.

Related Content

• The NGS FISS DDE Provider Online Guide includes how to use the HCPCS Inquiry within the FISS DDE system to check for valid HCPCS codes. Refer to Chapter IV – Inquiries Submenu for details on how to use this function

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 Error

Correct the HCPCS code and resubmit.

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

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

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

Avoiding/Correcting This Error

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

The 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 Error

Verify the HCPCS codes and units of service billed. Correct claims as necessary.

Condition code 'A6' is required when billing the influenza and/or pneumococcal vaccine and/or COVID-19 vaccine and their related administration codes.

Avoiding/Correcting This Error

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

Related Content

• Vaccines that are a Medicare covered benefit are included on the MLN Educational Tool “Medicare Preventive Services”
• During the COVID-19 Public Health Emergency certain COVID-19 vaccines are covered by Medicare. Refer to the CMS website “COVID-19 Vaccines and Monoclonal Antibodies” for the current list of COVID-19 vaccines.

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

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

or

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

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

Avoiding/Correcting This Error

Verify billing and correct where appropriate.

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

Related Content

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

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

Avoiding/Correcting This Error

HCPCS code for vaccines can be found on under the Medicare Preventive Services.      
 

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

Avoiding/Correcting This Error

If 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 Content

• CMS Flu Shot web page

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 Error

Verify billing and if appropriate, correct and resubmit.

Related Content

• Hospice Prescription Drug and Infusion Pump Reporting Job Aid

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 Error

Correct the NDC information and resubmit.

Related Content

• Hospice Prescription Drug and Infusion Pump Reporting Job Aid

One or more diagnosis codes are equal.

Avoiding/Correcting This Error

Verify the diagnosis codes reported on your claim and ensure the same information hasn’t been reported twice.

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.

Avoiding/Correcting This Error

Ensure 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

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 13 - Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services
• CMS Internet-Only Manual Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers

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

Avoiding/Correcting This Error

If this is correct, follow MSP billing guidelines and submit the claim accordingly.

If this is incorrect. as part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. 

If you have information that disputes open records, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):

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

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

Fax: 405-869-3307

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

Related Content

• Medicare Secondary Payer section

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

Check 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):

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

Related Content

• Medicare Secondary Payer

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

Avoiding/Correcting This Error

Check 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):

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

Related Content

• Medicare Secondary Payer

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

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct: reformat as secondary and resubmit.

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

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

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

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

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct, reformat as secondary and resubmit.

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

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

Telephone number: 855-798-2627

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

Avoiding/Correcting This Error

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

Related Content

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

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

Avoiding/Correcting This Error

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

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

Fax: 405-869-3307

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

Related Content

• Medicare Secondary Payer

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

Avoiding/Correcting This Error

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

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

Related Content

• Collect and Report Retirement Dates on Medicare Claims
• Contacting the BCRC, refer to Correct a Beneficiary's MSP Record
• Correct or Adjust a Claim Due to an MSP-Related Issue
• Prevent an MSP Rejection on a Medicare Primary Claim

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

Avoiding/Correcting This Error

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

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

Fax: 405-869-3307

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

Related Content

• Medicare Secondary Payer

The claim was submitted as Medicare primary 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

• If the MSP record is correct, submit the claim to the primary LGHP. Once you receive payment, you may submit an adjustment (TOB XX7) to this claim to change it to an MSP claim.
• If the MSP record is incorrect because the beneficiary and/or spouse retired, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed) and code the beneficiary’s retirement date with OC 18 and/or the spouse’s retirement date with OC 19.
• If the MSP record is incorrect because of a reason other than retirement, contact the BCRC to request the record be updated. BCRC contact information:
  • Telephone: 855-798-2627 or TTY/TTD: 855-797-2627 (for hearing and speech impaired), available Monday-Friday, 8:00 a.m.–8:00 p.m. ET (except holidays)
  • Address for general MSP correspondence: Medicare:
    MSP general correspondence
    P.O. Box 138897, Oklahoma City, OK 73113-8897
  • Follow instructions in CMS article SE1416 (which may require you to fax the BCRC at Fax: 405-869-3307)
• Once the BCRC updates the MSP record, you may submit an adjustment to this claim to change it to Medicare primary (as originally billed).  

Do not resubmit claims rejected for reason code 34540 as they will be rejected as duplicates.

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct: reformat as secondary and resubmit.

If records are not correct and you have information that disputes the records, please contact the BCRC, Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):

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

Address for general MSP correspondence: 

Medicare - MSP general correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897

• Fax: 405-869-3307

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

Avoiding/Correcting This Error

The claim should be billed to the primary insurer.

If records are correct: reformat as secondary and resubmit.

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

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

Toll free: 800-999-1118

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

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

Avoiding/Correcting This Error

If this is correct, follow MSP billing guidelines and submit the claim accordingly.

If this is incorrect. as part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. 

If you have information that disputes open records, please contact the BCRC Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):

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

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

Fax: 405-869-3307

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

Related Content

• Medicare Secondary Payer

The 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 Error

When 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.

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 Error

If 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.

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 Error

If 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.

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 Error

Verify the occurrence codes billed. Correct claims as necessary.

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 Error

Remove the value code 78 from the hospice claim (TOB 81X/82X) and resubmit the claim.

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 Error

Correct the CBSA code and resubmit.

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 Error

Correct the CBSA code and resubmit.

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 Content

Providers 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)

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

Avoiding/Correcting This Error

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

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

Related Content

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

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.

Avoiding/Correcting This Error

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. 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.

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.

Avoiding/Correcting This Error

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. 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.

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

If duplicate claim was submitted in error, no additional provider action is necessary. If it is determined that the claim was due to additional charges for a patient for a specific date of service, wait for the original claim to finalize and adjust (TOB XX7) the originally-processed claim.

Prior to submitting a claim, ensure you have received the charges from all departments so you can submit one claim with all of the services rendered. Utilize the IVR system, NGSConnex or FISS to determine whether a claim has already been submitted for this date of service.

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

Prior 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.

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

An adjustment bill must be submitted

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

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

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 Error

Verify the from and through dates, the HCPCS codes and the line item dates of service for the lab charges. 

• If the information on the incoming claim is correct, an adjustment claim (TOB XX7) must be filed to add the charges to the processed claim.             
• If the information on the incoming claim is in error, make corrections and resubmit the claim.

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 Error

Check the claims submitted by your agency for the patient:

• The HCPCS codes are for vaccines – you may only bill one flu vaccine per season, per patient
  • The pneumococcal vaccine may only be administered once per beneficiary
• If appropriate, make corrections and resubmit a new claim

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 Error

If 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 Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40.1

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 Error

If 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 Content

• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 40.1

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

This 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 Error

This 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.

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 Error

This 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.

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 Error

This 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.

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

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

Avoiding/Correcting This Error

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

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

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

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

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

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

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

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

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

Avoiding/Correcting This Error

This reason code may be applied when 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.

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

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

Avoiding/Correcting This Error

This reason code may be applied when 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.

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 Error

This 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.

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 Error

This 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.

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

• MBI
• Provider number
• LIDOS

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

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

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

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 Error

All 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.

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 Error

All 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.

The requested nonmedical information was not received timely.

Avoiding/Correcting This Error

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

The requested nonmedical information was not received timely. 

Avoiding/Correcting This Error

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

The requested nonmedical information was not received timely. 

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

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

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

Avoiding/Correcting This Error

• Access MAP171D on the FISS/DDE Provider Online System for the line item detail medical review reason code
  • MAP171D can be accessed through claim option 12 by selecting <PF2> once or <PF11> twice from Claim Page 2 to access MAP171D)
• Since it is possible for each line item to have a different line item denial you would want to review the additional lines that were denied
  • To perform this function you <PF6> to forward to the next claim line and <PF5> to go back through previous claim lines

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. Providers can access MAP171D for line item detail information:

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

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

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. You can access MAP171D for line item detail information:

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

Verify the line level rejection information to determine the rejection for each of the lines of the claim in question. You can access MAP171D for line item detail information:

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

Avoiding/Correcting This Error

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

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

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

Avoiding/Correcting This Error

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

Related Content

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

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 Error

As appropriate, submit plan of treatment to support the need for services to the Appeals Department for review.

Related Content

• Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 Section 10.3.6

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 Error

As appropriate, submit plan of treatment to support the need for services to the Appeals Department for review.

Related Content

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 10 Section 10.3.6

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

Avoiding/Correcting This Error

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

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

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

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

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

Related Content

• Appeals section of our website

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

Avoiding/Correcting This Error

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

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

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

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

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

Related Content

• Appeals section of our website

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

Avoiding/Correcting This Error

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

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

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

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

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

Related Content

• Appeals section of our website

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

Avoiding/Correcting This Error

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

Additional Information

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

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

Avoiding/Correcting This Error

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

Additional Information

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

This 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 Error

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

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

Review the coverage and billing relevant to NCD 20.4 prior to rendering the services.

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

Related Content

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

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

Avoiding/Correcting This Error

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

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 Error

Verify 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.

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 Error

Verify 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.

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

Avoiding/Correcting This Error

Review the narrative in the Remarks on claim page 4 and make any necessary corrections then return the claim to your intermediary.

An unacceptable principle diagnosis code was billed on this claim.

Avoiding/Correcting This Error

The 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

• CMS MLN Matters Publication Items and Services Not Covered Under Medicare
• CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB)
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB).

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

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

Avoiding/Correcting This Error

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

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

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

Related Content

CMS MLN Matters Publication Items and Services Not Covered Under Medicare

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 Error

If 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

• 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)
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB)
• CMS MLN Matters Publication Items and Services Not Covered Under Medicare

Clarify reason for discharge.

Avoiding/Correcting This Error

Remarks 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 Content

• Avoiding Reason Code 7C625: Appropriate Use of Remarks on Final Hospice Claims Job Aid
• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual Coverage of Hospice Services Under Hospital Insurance, Chapter 9, Section 60

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 Error

Verify the CBSA code reported on your RAP claim. CBSA codes can be found in the HH PPS Wage Index File on the CMS website.

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

Avoiding/Correcting This Error

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

Related Content

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

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.

Avoiding/Correcting This Error

• If CWF records indicate Medicare is primary then reformat the claim and ensure all MSP coding is removed before resubmitting the claim.
• If CWF indicates another insurer is primary then reformat the claim with Medicare secondary with the correct billing and primary payer information.
• If you have information that disputes the CWF records then contact the BCRC directly:
  • BCRC Customer Service Representatives are available to assist you Monday through Friday, from 8:00 a.m. to 8:00 p.m., Eastern Time, except holidays, at toll-free lines: 855-798-2627
    (TTY /TTD: 855-797-2627 for the hearing and speech impaired).
    • Address for general correspondence is:
      Medicare - Data Collections
      P.O. Box 138897
      Oklahoma City, OK 73113-8897
      Fax: 405-869-3307
• If billing conditionally, a two-digit explanation code is required in the Remarks section of the claim and must include one of the following: NB, PC, CD, FG or BE. Include the benefits exhaust date when using BE. Include the reason for denial when using FG
• Make corrections and resubmit the claim

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

Avoiding/Correcting This Error

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

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

If appropriate, make corrections and resubmit a new claim.

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

Avoiding/Correcting This Error

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

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

If appropriate, make corrections and resubmit a new claim.

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 Error

Check 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.

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 Error

Use CWF to identify hospice beneficiary (information also available in IVR, NGSConnex). View dates indicating election period. Review revocation indicator:

• Blank/0 = No revocation on file
• Code 1 = Revoked by beneficiary
• Code 2 = Revoked by MAC

If claim’s DOS fall within hospice election period, determine whether services are related to terminal illness.

• If yes, do not submit claim to Medicare. Instead submit claim to hospice agency
• If no, send claim to Medicare reporting CC07. CC07 indicates service not related to the beneficiary’s hospice condition (terminal illness)

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

Avoiding/Correcting This Error

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

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

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

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

• Verify the dates of service on the claim
• Check HIQA for inpatient hospital dates
• A home health episode claim may have dates of service on an inpatient hospital admission date or inpatient hospital discharge date, but may not have service dates that fall within the inpatient hospital stay

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

• Verify the dates of service on the claim
• Check HIQA for inpatient hospital dates
• A home health episode claim may have dates of service on an inpatient hospital admission date or inpatient hospital discharge date, but may not have service dates that fall within the inpatient hospital stay

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

Avoiding/Correcting This Error

Many 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.

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

Avoiding/Correcting This Error

Many 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.