- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
Table of Contents
- Reason Codes T5052, N5052, U5210, U5220 and U5200 - Preventing RTP and Rejection Claims
- Why Is Beneficiary Eligibility Verification Important?
- Enhancing Your Facility’s Beneficiary Eligibility Verification Process
- Provider Action
- Useful Tools
- Related Content
Reason Codes T5052, N5052, U5210, U5220 and U5200 - Preventing RTP and Rejection Claims
All Medicare providers are responsible for verifying a beneficiary’s Medicare eligibility prior to submitting a claim for reimbursement. Proactive providers make beneficiary eligibility verification part of their registration/admissions process. Beneficiary eligibility issues, that can be easily identified and resolved prior to claim submission, cause claims to reject and RTP.
Why Is Beneficiary Eligibility Verification Important?
A review of the data for the claims that were processed for providers in JK indicates a significant increase in claim rejection and RTP reason codes related to a beneficiary’s entitlement/eligibility to Medicare benefits. These errors result in no Medicare reimbursement and require time-consuming follow-up for resolution. Following the guidance outlined in this article, providers can avoid these costly errors and help to ensure compliant claim submission.
Enhancing Your Facility’s Beneficiary Eligibility Verification Process
As beneficiaries undergo the registration/admissions process, they should be asked to provide insurance information, including proof of Medicare coverage (i.e., Medicare card). Changes in a patient’s Medicare coverage would not be reflected on the card. It is paramount to accurate claim submission that providers use available self-service tools to verify a patient’s enrollment in the Medicare Program.
Provider Action
- Verify the Spelling of the Beneficiary’s First and Last Name
- An increase in RTP reason code N5052 has been recently noted. This reason code is applied to claims when the spelling of the beneficiary’s name on the Medicare claim differs from the information in the beneficiary’s master file. Be sure that any special characters (including apostrophes, dashes, commas) and suffixes (Jr., Sr., III) that are included on the Medicare file are also reflected on your claim.
If the spelling of the name on the Medicare card (or as reported by the patient) does not match the Medicare file, the patient should contact the Social Security office to make appropriate corrections to the Medicare file. Once the file is updated, a claim for services can be submitted.
- An increase in RTP reason code N5052 has been recently noted. This reason code is applied to claims when the spelling of the beneficiary’s name on the Medicare claim differs from the information in the beneficiary’s master file. Be sure that any special characters (including apostrophes, dashes, commas) and suffixes (Jr., Sr., III) that are included on the Medicare file are also reflected on your claim.
- Review the Beneficiary’s HICN
- RTP reason code N5052 also applies to claims when the beneficiary’s HICN differs from what is reflected in Medicare’s records. A beneficiary’s HICN may be updated if coverage changes, such as when the beneficiary who was previously covered under their spouse’s Medicare benefits becomes entitled to their own Medicare benefits. Claims submitted under the previously active HICN will receive this claim reason code. Additionally, a rise in RTP reason code T5052 has been noted. This reason code applies to claims that are submitted for patients who are not entitled to Medicare coverage. The eligibility verification process should identify incorrect or invalid HICN so that you can resolve this issue prior to claim submission.
- RTP reason code N5052 also applies to claims when the beneficiary’s HICN differs from what is reflected in Medicare’s records. A beneficiary’s HICN may be updated if coverage changes, such as when the beneficiary who was previously covered under their spouse’s Medicare benefits becomes entitled to their own Medicare benefits. Claims submitted under the previously active HICN will receive this claim reason code. Additionally, a rise in RTP reason code T5052 has been noted. This reason code applies to claims that are submitted for patients who are not entitled to Medicare coverage. The eligibility verification process should identify incorrect or invalid HICN so that you can resolve this issue prior to claim submission.
- Compare the Claim’s DOS to the Beneficiary’s Medicare Part A and Medicare Part B Effective and Termination Dates
- Medicare Part A enrollment must be in effect for hospital or SNF inpatient services to be covered. Medicare Part B enrollment must be in effect for outpatient services to be covered. We have seen a spike in claims rejecting due to a beneficiary not being entitled to Medicare coverage during the date(s) of service. When services are provided prior to a beneficiary’s Medicare Part A or Part B entitlement date, claims will be rejected with reason code U5210. Claims for services reported after a beneficiary’s Medicare Part A or Part B termination date are rejected with reason code U5220. For claims where inpatient services are reported and the beneficiary’s Part A coverage is not in effect, or where outpatient services are reported and the beneficiary’s Part B coverage is not in effect, rejection reason code U5200 is applied. Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period.
Useful Tools
- Health Insurance Query-A System
- Providers can access Medicare beneficiary eligibility information by reviewing the Medicare master file via the HIQA system. Page 1 of HIQA outlines the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates. To access HIQA, providers must have an FISS DDE logon ID and password.
- Providers can access Medicare beneficiary eligibility information by reviewing the Medicare master file via the HIQA system. Page 1 of HIQA outlines the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates. To access HIQA, providers must have an FISS DDE logon ID and password.
- NGSConnex Online Web Application
- The NGSConnex online web application application is another tool that pulls beneficiary eligibility information from the Medicare master file. From the Entitlement tab, providers can verify the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates.
- The NGSConnex online web application application is another tool that pulls beneficiary eligibility information from the Medicare master file. From the Entitlement tab, providers can verify the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates.
- IVR System
- The IVR system is a telephone application that also pulls beneficiary eligibility information from the Medicare master file. The IVR will verify the beneficiary’s Medicare Part A and Part B effective and termination dates.
- The IVR system is a telephone application that also pulls beneficiary eligibility information from the Medicare master file. The IVR will verify the beneficiary’s Medicare Part A and Part B effective and termination dates.
- HIPAA HETS 270/271 Application
- The HETS application provides the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates.
- The HETS application provides the spelling of the beneficiary’s first and last name, corrections to the HICN, if applicable, and the Medicare Part A and Part B effective and termination dates.
- National Government Services Top Claim Errors Website
- Stay informed of the JK top reason code errors. The top claim errors are available for review the reason codes listed on a monthly basis. This resource is useful for providers whose claims have been plagued by the top rejections and RTPs, as well as those providers who utilize the guidance to avoid these reason codes.
- Providers should take all of the recommended actions to avoid and prevent these reason codes from reoccurring. This can be done by recognizing these reoccurring reason codes and making changes to your internal procedures and policies. When conducting the beneficiary eligibility process, in addition to verifying the spelling of the beneficiary’s name and HICN, and the dates for Medicare Part A and Part B entitlement, providers should complete a thorough review. Be sure to check for all eligibility elements that could cause the claim to RTP or reject, such as identifying whether there is MSP involvement, an effective MAO enrollment or if the beneficiary has elected hospice coverage.
- Conducting a comprehensive verification of eligibility prior to submitting the claim can prevent unnecessary claim rejections and RTP, loss of staff time and revenue, and incurring the cost of adjusting and/or resubmitting claims.
Related Content
- HIPAA Eligibility Transaction System (HETS) Help (270/271) - CMS website
- Interactive Voice Response System
- NGSConnex online application
- Top Claim Errors