Using the Interactive Voice Response to Avoid Eligibility and Entitlement Related Claim Rejections and Return to Provider
Some of the top claim submission errors causing Medicare claims to reject or RTP can be easily avoided by taking advantage of the IVR application. Registration staff can quickly and accurately verify information provided by the beneficiary to determine Medicare eligibility and/or entitlement.
These reason codes identify some of the errors that a call to the IVR could avoid:
- Rejection Reason Code T5052: CMS records indicate the beneficiary is not in file.
- Rejection Reason Code U5200: CMS records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim.
- Rejection Reason Code U5210: The beneficiaryʹs entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim.
- RTP Reason Code N5052: CWF indicates the beneficiaryʹs name and health insurance card number do not match.
- Rejection Reason Code C7010: An inpatient, outpatient, or home health claim has service dates overlapping a hospice election period and condition code 07 is not present.
- Rejection Reason Code U5233: The admission date on this inpatient PPS claim falls within the enrollment period of a risk HMO. This edit also applies to non‐PPS inpatient, SNF inpatient, and all outpatient claims where the statement covered period falls within or overlaps an enrollment period in a risk HMO.
The IVR gathers data from the CWF, providing the same information that is available to CCRs. By using this self‐service tool, providers can verify the following beneficiary eligibility and entitlement information:
- Part A & Part B effective & termination dates
- Date of Death
- MSP type, insurer name & address, effective & termination dates
- MAO plan number, name, address, telephone number, effective & termination dates
- Last inpatient billing date
- Full & coinsurance hospital, SNF days remaining
- LTR days remaining
- Current and prior year Part B deductible amount met
- Current and prior year physical & occupational therapy limit amount met
- Home health name, address, effective & termination dates
- Hospice name, address, effective & termination dates
- Corrected MBI
- Remaining psychiatric days