Reason Code | Description | Error Type | Details |
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32415 | Condition code ‘A6’ is required when one or more of the following HCPCS are present on the claim: HCPCS Q0124 with from date less than 1/1/1995 or 90655–90660, 90724, 90732, G0008, G0009 or G9141 or HCPCS G9017–G9020, G9033–G9036, and from date 12/1/2004 through 5/31/2005. HCPCS 90658 is termed effective 12/31/2010 and replaced by HCPCS Q2035–Q2039 effective 10/1/2010.
|
RTP |
Claim Error Reason Code 32415Error Description
Condition code ‘A6’ is required when one or more of the following HCPCS are present on the claim: HCPCS Q0124 with from date less than 1/1/1995 or 90655–90660, 90724, 90732, G0008, G0009 or G9141 or HCPCS G9017–G9020, G9033–G9036, and from date 12/1/2004 through 5/31/2005. HCPCS 90658 is termed effective 12/31/2010 and replaced by HCPCS Q2035–Q2039 effective 10/1/2010.
Avoiding/Correcting This ErrorVerify billing and correct where appropriate. Related Content
Reviewed: Jul 16, 2024 |
34072 | Claims were submitted as Medicare primary and a positive working elderly record exists at CWF. The claim was submitted with an occurrence code 18, however the retirement date is the same as or prior to the effective date of the CWF MSPA record/s or is equal to the claim from date. The occurrence code 25 date benefits terminated by the primary payer is prior to dates of service and not equal to the occurrence code 18 (Retirement date). Or, occurrence code 25 is within or after the dates of service but there is an MSPA record which has the spouse as the policy holder. |
RTP |
Claim Error Reason Code 34072Error Description
Claims were submitted as Medicare primary and a positive working elderly record exists at CWF. The claim was submitted with an occurrence code 18, however the retirement date is the same as or prior to the effective date of the CWF MSPA record/s or is equal to the claim from date. The occurrence code 25 date benefits terminated by the primary payer is prior to dates of service and not equal to the occurrence code 18 (Retirement date). Or, occurrence code 25 is within or after the dates of service but there is an MSPA record which has the spouse as the policy holder. Avoiding/Correcting This ErrorProviders can currently check MSPA records thru HIQA, NGSConnex. If the records on CWF need updated this is handled by BCRC. Verify the retirement date (occurrence code 18) and make changes if needed. If the retirement date is correct, add coding to indicate the date was verified and correct and resubmit the claim. Clarify if occurrence code 25 is for the record of the spouse and add claim coding and resubmit the claims.
Reviewed: Jul 16, 2024 |
34293 | Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34293Error Description
Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct: reformat as secondary and resubmit. If the records are incorrect, please contact the BCRC; Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays):
Medicare ‒ MSP General Correspondence Reviewed: Jul 16, 2024 |
34295 | Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34295Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct, reformat as secondary and resubmit. If records are not correct and you have information that disputes the records, please contact the Benefits Coordination & Recovery Center: Medicare - MSP General Correspondence Telephone number: 855-798-2627 Reviewed: Jul 16, 2024 |
34538 | Hospice: Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. |
Rejection |
Claim Error Reason Code 34538Error Description
Hospice: Claim submitted as Medicare primary and a positive working elderly record exists at CWF. The claim should be billed to the primary insurer. Avoiding/Correcting This ErrorIf this is correct: Follow MSP billing guidelines and submit the claim accordingly. If this is incorrect: As part of a provider’s eligibility verification process for Medicare beneficiaries, which is required to be conducted before claims are submitted to Medicare, providers should be checking for MSP file(s) on CWF. If you have information that disputes open records - we are not the Medicare office that manages those files. Please contact the BCRC: Monday‒Friday, 8:00 a.m.‒8:00 p.m. ET (except holidays)
Address for general MSP correspondence: Fax: 405-869-3307 In addition, providers should utilize all available/applicable condition codes, occurrence codes and remarks opportunities when submitting Medicare primary claims when there is an active MSP file on CWF. Related ContentReviewed: Jul 16, 2024 |
34538 | The claim was submitted as Medicare primary and a positive working aged record exists at CWF. |
Rejection |
Claim Error Reason Code 34538Error Description
The claim was submitted as Medicare primary and a positive working aged record exists at CWF. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct, reformat and resubmit as secondary. If you have information that disputes open records, please contact the BCRC at 855-798-2627. Related Content
Reviewed: Jul 16, 2024 |
34538 | The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason Code 34538Error Description
The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). Avoiding/Correcting This Error
Related Content
Reviewed: Jul 16, 2024 |
The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason CodeError Description
The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date).
Avoiding/Correcting This Error
Related Content
Reviewed: Jul 16, 2024 |
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34538 | The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). |
Rejection |
Claim Error Reason Code 34538Error Description
The claim was submitted as Medicare primary but an open MSP Working Aged record (VC = 12; Payer Code = A) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date). Avoiding/Correcting This Error
Do not resubmit claims rejected for reason code 34538 as they will be rejected as duplicates. Related Content
Reviewed: Jul 16, 2024 |
34540 | The claim was submitted as Medicare primary but an open MSP Disability record (VC = 43; Payer Code = G) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date/last date on which beneficiary or spouse was actively employed). |
Rejection |
Claim Error Reason Code 34540Error Description
The claim was submitted as Medicare primary but an open MSP Disability record (VC = 43; Payer Code = G) is in CWF and the claim did not contain the reason Medicare is primary (such as a retirement date/last date on which beneficiary or spouse was actively employed). Avoiding/Correcting This Error
Related ContentReviewed: Jul 16, 2024 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. This claim should be submitted to the primary insurer. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. This claim should be submitted to the primary insurer. Avoiding/Correcting This ErrorIf the records are correct, reformat as Medicare secondary; the Medicare Secondary Payer page on our website provides direction. If the records need to be updated, you will need to contact the BCRC at 855-798-2627 or written inquiry: MSP General Correspondence Reviewed: Jul 16, 2024 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. Avoiding/Correcting This Error
Related ContentReviewed: Jul 16, 2024 |
34540 | Claim submitted as Medicare primary and a positive disability record exists at CWF. |
Rejection |
Claim Error Reason Code 34540Error Description
Claim submitted as Medicare primary and a positive disability record exists at CWF. Avoiding/Correcting This ErrorThe claim should be billed to the primary insurer. If records are correct: reformat as secondary and resubmit. If records are not correct and you have information that disputes the records, please contact the BCRC: Medicare - Coordination of Benefits Toll free: 800-999-1118 You can find additional information on VA transfers in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, Section 60. (319 KB) Reviewed: Jul 16, 2024 |
34963 | The attending physician information on claim page 5 is not correct due to:
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RTP |
Claim Error Reason Code 34963Error Description
The attending physician information on claim page 5 is not correct due to:
Avoiding/Correcting This ErrorVerify billing and, if appropriate correct and return the claim. Online providers should press PF9 to restore the claim. Related Content
Reviewed: Jul 16, 2024 |
34977 | Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. |
RTP |
Claim Error Reason Code 34977Error Description
Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. Avoiding/Correcting This ErrorIf you are billing for on-campus services only:
Please verify billing and, if appropriate, correct by updating the practice address on the claim to exactly match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS. Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
34977 | Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. |
RTP |
Claim Error Reason Code 34977Error Description
Practice address issue: Claim level reason code appliable to a 13X or 14X TOB. The practice address present on the claim does not match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. Avoiding/Correcting This ErrorIf you are billing for on-campus services only:
Please verify billing and, if appropriate, correct by updating the practice address on the claim to exactly match the address on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or in PECOS. Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
34985 | The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim.
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RTP |
Claim Error Reason Code 34985Error Description
The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim.
Avoiding/Correcting This ErrorThe PO modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus provider-based outpatient department (PBD). The PO modifier applies to a grandfather/excepted PBD. Grandfathered means that the facility became PD before 11/2/2015. Please verify billing and, if appropriate correct by updating the PO modifier to the applicable claim line(s). Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
34985 | The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim. |
RTP |
Claim Error Reason Code 34985Error Description
The PO modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PO modifier is not present on the claim. Avoiding/Correcting This ErrorThe PO modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus provider-based outpatient department (PBD). The PO modifier applies to a grandfather/excepted PBD. Grandfathered means that the facility became PD before 11/2/2015. Please verify billing and, if appropriate correct by updating the PO modifier to the applicable claim line(s). Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
34986 | The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim. |
RTP |
Claim Error Reason Code 34986Error Description
The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim. Avoiding/Correcting This ErrorThe PN modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus outpatient, PBD of a hospital. The PN modifier applies to a grandfather/excepted PBD for DOS on/after 1/1/2017. Non-grandfathered means that the off-campus practice location has an effective date on or after 11/2/2015. Please verify billing and, if appropriate correct by updating the PN modifier to the applicable claim line(s). Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
34986 | The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim. |
RTP |
Claim Error Reason Code 34986Error Description
The PN modifier is missing from one or more claim lines. Claim level reason code appliable to a 13X or 14X TOB. A practice location is present on the claim and matches to an entry on the Provider Practice Address Query Screen (MAP1AB2) in FISS DDE or PECOS. However, the PN modifier is not present on the claim. Avoiding/Correcting This ErrorThe PN modifier is used on all claim lines for all services, procedures and/or surgeries provided at an excepted off-campus outpatient, PBD of a hospital. The PN modifier applies to a grandfather/excepted PBD for DOS on/after 1/1/2017. Non-grandfathered means that the off-campus practice location has an effective date on or after 11/2/2015. Please verify billing and, if appropriate correct by updating the PN modifier to the applicable claim line(s). Online Providers: Press PF9 to store the claim. Other Providers: Return to the MAC. Related Content
Reviewed: Jul 16, 2024 |
37098 | FQHC PPS supplemental rate is not present for the MA-plan. |
RTP |
Claim Error Reason Code 37098Error Description
FQHC PPS supplemental rate is not present for the MA-plan. Avoiding/Correcting This ErrorSubmit an estimate of the average MA payments (per visit basis) for covered FQHC services to NGS (for the first two rate years). Submit a documented estimate of the average per visit payment for MA enrollees, for each MA plan you contract with, and any other information as may be required to enable NGS to accurately establish an interim supplemental payment. Expected payments from the MA organization would only be used until actual MA revenue and visits collected on the FQHC’s cost report can be used to establish the amount of the supplemental payment. Related ContentCMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 9 - Rural Health Clinics/ Federally Qualified Health Centers, Section 60.4 - Billing for Supplemental Payments to FQHCs under Contract with Medicare Advantage (MA) Plans Reviewed: Jul 16, 2024 |
38001 | This claim (11X, 18X) rejected because it contains service dates that equal or overlap a previously denied claim. |
Rejection |
Claim Error Reason Code 38001Error Description
This claim (11X, 18X) rejected because it contains service dates that equal or overlap a previously denied claim. Avoiding/Correcting This ErrorReview the rejected and previously denied claims. Verify all information billed. If appropriate, make an adjustment or cancel to the previously processed denied claim or make corrections and submit a corrected adjustment claim. Related Content
Reviewed: Jul 16, 2024 |
38032 | The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. |
Rejection |
Claim Error Reason Code 38032Error Description
The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38032 | The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. |
Rejection |
Claim Error Reason Code 38032Error Description
The claim is a duplicate of a previously processed outpatient claim, where the dates of service are the same and at least one revenue code and one diagnosis code matches the original claim. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38038 | Whether any revenue code lines are equal or not, OPPS bill types (12X, 13X, 14X, 76X, 75X, 34X, or any bill containing condition code 07) cannot have overlapping dates when the provider numbers are equal, unless condition code G0 or 20 or 21 is present on the claim. |
RTP |
Claim Error Reason Code 38038Error Description
Whether any revenue code lines are equal or not, OPPS bill types (12X, 13X, 14X, 76X, 75X, 34X, or any bill containing condition code 07) cannot have overlapping dates when the provider numbers are equal, unless condition code G0 or 20 or 21 is present on the claim. Avoiding/Correcting This ErrorCheck OPPS claims for potential overlapping dates of service prior to claim submission and bill accordingly An adjustment bill must be submitted
Reviewed: Jul 16, 2024 |
38050 | This claim is a duplicate of a previously submitted home health claim. The first two positions of the TOB are 32X, 33X or 34X and the following fields on the history and processing claim are the same.
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Rejection |
Claim Error Reason Code 38050Error Description
This claim is a duplicate of a previously submitted home health claim. The first two positions of the TOB are 32X, 33X or 34X and the following fields on the history and processing claim are the same.
Avoiding/Correcting This ErrorCheck your remittance advice or the claims processing system for a previously submitted/processed claim before submitting any new billing. Reviewed: Jul 16, 2024 |
38117 | All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. |
RTP |
Claim Error Reason Code 38117Error Description
All inpatient SNF and non PPS bills must be processed in sequence. There is a prior claim for this admission pending in our system. Avoiding/Correcting This ErrorIf there is a prior claim for this admission pending in our system, verify the admission date and from date on this claim. If admission and from dates are correctly reported, please hold this claim until the pending bill has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may resubmit the next claim. Prior to billing, verify the admission date and from date on this claim. Verify that claims are submitted in date of service order. Verify previous claim has completed processing and has shown on your remittance advice. Once the prior claim has shown on the remittance advice, you may submit the next claim. Related ContentReviewed: Jul 16, 2024 |
38119 | Effective with admissions on and after 4/1/1995, all inpatient SNF and non-PPS bills must be processed in sequence. We have not received the claim immediately preceding the dates of service on this bill. |
RTP |
Claim Error Reason Code 38119Error Description
Effective with admissions on and after 4/1/1995, all inpatient SNF and non-PPS bills must be processed in sequence. We have not received the claim immediately preceding the dates of service on this bill. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38119 | This claim reports DOS that are part of a continuing stay. We have not received the claim immediately preceding the DOS on this bill. |
RTP |
Claim Error Reason Code 38119Error Description
This claim reports DOS that are part of a continuing stay. We have not received the claim immediately preceding the DOS on this bill. SNF inpatient claims have to be processed in sequence. That means that when the beneficiary is going to be in the SNF as an inpatient for several months in a row, claims for the months the beneficiary is in the SNF must be submitted one at a time, in sequential order. Subsequent claims in the stay should not be submitted until the prior month’s claim has processed and finalized. Avoiding/Correcting This ErrorSubmit continuing-stay claims one month at a time and allow the claim to process before submitting the next month’s claim.
Reviewed: Jul 16, 2024 |
38200 | This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
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Rejection |
Claim Error Reason Code 38200Error Description
This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorAlways verify the status of a submitted claim before submitting another claim. Verify claim status using the IVR system, FISS/DDE or the NGSConnex online portal. Per CMS mandate, PCC representatives are not permitted to provide claim status over the telephone. You can find the appropriate IVR telephone number on our website under Contact Us. Even though Medicare payments are generally made 14 days after submission for electronic claims (29 days for paper claims), you should not use this as a guideline for resubmitting a claim. If you submitted the duplicate claim in error and one of the claims paid, no additional action is required. If you submitted the duplicate claim in error and both claims rejected, resubmit one of the claims. If you submitted the duplicate claim to provide additional information for or to change the original claim, then adjust the original claim. If the original claim has not yet finalized, then wait for that claim to finalize (must appear on your remittance) and then submit the adjustment. Reasons to adjust claims include, but are not limited to:
Reviewed: Jul 16, 2024 |
38312 | FQHC PPS claim with a LIDOS that matches another LIDOS on a previously submitted claim and all of the following match:
If appropriate make corrects and resubmit a new claim to the MAC. |
Rejection |
Claim Error Reason Code 38312Error Description
FQHC PPS claim with a LIDOS that matches another LIDOS on a previously submitted claim and all of the following match:
If appropriate make corrects and resubmit a new claim to the MAC. Avoiding/Correcting This ErrorBefore submission of the claim, ensure that no other claim was previously billed and processed with the same line item date of service. If another claim was processed with the same line item date of service, an adjustment to the processed claim will need to be submitted as an XX7 type of bill to include all charges for claim. Reviewed: Jul 16, 2024 |
38312 | This FQHC PPS claim reports a line item DOS that matches another line item DOS on a previously submitted claim for the same beneficiary. |
Rejection |
Claim Error Reason Code 38312Error Description
This FQHC PPS claim reports a line item DOS that matches another line item DOS on a previously submitted claim for the same beneficiary. Avoiding/Correcting This ErrorMake sure services provided are submitted for reimbursement once. If additional services need to be added to a submitted claim, wait for that claim to process. Then adjust the processed claim to add the additional services. Reviewed: Jul 16, 2024 |
39721 | The requested nonmedical information was not received timely. |
Rejection |
Claim Error Reason Code 39721Error Description
The requested nonmedical information was not received timely. Avoiding/Correcting This ErrorTo have this claim considered for payment submit a new electronic billing with the requested information. Reviewed: Jul 16, 2024 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Related ContentReviewed: Jul 16, 2024 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, return to the claim and follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Reviewed: Jul 16, 2024 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Related ContentReviewed: Jul 16, 2024 |
39929 | Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Related ContentReviewed: Jul 16, 2024 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorReview each line level denial reason code(s). Follow the steps provided in that line level reason code narrative. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Important: Claims and claim line items that have been medically denied cannot be adjusted; providers must go through the appeals process to submit documentation to support any changes to denied line items. Related ContentReviewed: Jul 16, 2024 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorVerify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Reviewed: Jul 16, 2024 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorReview each line level denial reason code(s). Follow the steps provided in that line level reason code narrative. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Important: Claims and claim line items that have been medically denied cannot be adjusted; providers must go through the appeals process to submit documentation to support any changes to denied line items. Related ContentReviewed: Jul 16, 2024 |
39934 | All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. |
Rejection |
Claim Error Reason Code 39934Error Description
All revenue code lines on the claim denied as noncovered and one or more of the lines denote beneficiary liability. Avoiding/Correcting This ErrorVerify the line level denial/reject information to determine the applicable reason code for each of the lines of the claim in question. Resubmit as appropriate. Line level reason code(s) appear on the right view of claim page two (MAP171D). In order to access the right view, review the reason codes, and return to the claim, follow these steps:
Press<F10>/<PF10> twice to go back to the left view of claim page two or press <F8>/<PF8> to go to claim page three. Reviewed: Jul 16, 2024 |
7C625 | Hospice: Status is 01. Check discharge reason and OC. |
RTP |
Claim Error Reason Code 7C625Error Description
Hospice: Status is 01. Check discharge reason and OC. Avoiding/Correcting This ErrorHospice – Clarify reason for discharge. Claim is being returned for one of the following reasons:
Reviewed: Jul 16, 2024 |
7K073 | This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. |
Rejection |
Claim Error Reason Code 7K073Error Description
This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. Avoiding/Correcting This ErrorIf the beneficiary is entitled to Medicare Part B, an ancillary claim may be submitted to your MAC. Related ContentReviewed: Jul 16, 2024 |
7K073 | This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. |
Rejection |
Claim Error Reason Code 7K073Error Description
This claim was submitted as noncovered with Occurrence Span Code 77 indicating that the provider is liable. Avoiding/Correcting This ErrorIf the beneficiary is entitled to Medicare Part B, an ancillary claim may be submitted to your MAC. Related ContentReviewed: Jul 16, 2024 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorIf services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient). Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex. If appropriate, make corrections and resubmit a new claim. Reviewed: Jul 16, 2024 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorIf services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient). Verify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system and FISS/DDE Provider Online System. If appropriate, make corrections and resubmit a new claim. Reviewed: Jul 16, 2024 |
C7010 | The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. |
Rejection |
Claim Error Reason Code C7010Error Description
The service date(s) on this claim overlap a hospice election period and condition code 07 is not present. Avoiding/Correcting This ErrorVerify hospice enrollment prior to claim submission by reviewing the CWF, the IVR system, and FISS/DDE Provider Online System or NGSConnex. If services are unrelated to hospice stay, resubmit with condition code 07 (treatment of nonterminal illness for hospice patient). If services are related, submit the claim to the hospice agency. Reviewed: Jul 16, 2024 |
U5065 | Home Health and Hospice: The claim From date is prior to the MBI effective date on the CWF crosswalk file and the MBI is the oldest occurrence in the crosswalk file. |
RTP |
Claim Error Reason Code U5065Error Description
Home Health and Hospice: The claim From date is prior to the MBI effective date on the CWF crosswalk file and the MBI is the oldest occurrence in the crosswalk file. Avoiding/Correcting This ErrorHHH may only bill services provided to the patient after the effective date of their Medicare coverage. Verify the effective date(s) for the MBI of the beneficiary prior to billing. If a new MBI has been issued to the beneficiary, all claims must be submitted with the new MBI. Related ContentReviewed: Jul 16, 2024 |
U5166 | Hospice: Hospice claim received and the ‘From’ date falls within an established hospice election period and the start “2” date is equal to zeros (no change of ownership or provider change has occurred). The provider number on this claim is not equal to provider “1” on established hospice election period. |
RTP |
Claim Error Reason Code U5166Error Description
Hospice: Hospice claim received and the ‘From’ date falls within an established hospice election period and the start “2” date is equal to zeros (no change of ownership or provider change has occurred). The provider number on this claim is not equal to provider “1” on established hospice election period. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
37364 | Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank. |
Rejection |
Claim Error Reason Code 37364Error Description
Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank. Avoiding/Correcting This ErrorThere was an issue with NOAs incorrectly editing for U537F. Once the system was fixed, NOAs could be resubmitted and subsequently processed. NOAs submitted late due to this issue may have affected more than one period of care claim. All claims affected should be submitted with modifier KX appended to the HIPPS code on the 0023 revenue line and Remarks specifying the request for exception to the late NOA penalty. Reviewed: Jul 16, 2024 |
37402 | Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code. |
RTP |
Claim Error Reason Code 37402Error Description
Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code. Avoiding/Correcting This ErrorHospice – This error occurs when a claim is submitted and the previous month's claim has not been found in the system or there is a gap between Through date of the previous claim and From date on this claim. Verify dates of service submitted on claim and ensure claims have been submitted in date order (no missing months). Note that there is a workaround when submitting adjustments to claims where there is a transfer in the benefit period. Enter the "Start Date 1" in the current benefit period as the admission date on the claim rather than the admission date. This will allow all days in the period to be counted in the RHC payment calculation. When resubmitting enter remarks: "adjust due to RHC errors SE17014." Reviewed: Aug 27, 2024 |
38031 | Hospice: This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
|
Rejection |
Claim Error Reason Code 38031Error Description
Hospice: This outpatient claim is a possible duplicate to a previously submitted outpatient claim and the following conditions exist:
Avoiding/Correcting This ErrorVerify the ‘from’ and ‘through’ dates, provider number, revenue codes, HCPCS codes, and line item date of service on the bill. If the claim is truly a duplicate; no action is necessary. Providers should develop and implement a process to ensure that duplicate claims are not being submitted. If all information is correct, add the charges from the incoming claim to those of the paid claim by submit an adjustment to the processed claim. Reviewed: Jul 16, 2024 |
38032 | Hospice: This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
|
Rejection |
Claim Error Reason Code 38032Error Description
Hospice: This outpatient claim is a duplicate of a previously processed outpatient claim. The following situations exist:
Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Jul 16, 2024 |
38037 | Hospice: This outpatient claim contains service dates that equal or overlap a previously submitted outpatient claim from your facility. At least one of the revenue codes or HCPCS codes match. |
Rejection |
Claim Error Reason Code 38037Error Description
Hospice: This outpatient claim contains service dates that equal or overlap a previously submitted outpatient claim from your facility. At least one of the revenue codes or HCPCS codes match. Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Jul 16, 2024 |
38054 | Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38054Error Description
Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38055 | Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38055Error Description
Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38200 | Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
|
Rejection |
Claim Error Reason Code 38200Error Description
Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorThis reason code may be applied when an NOA and period of care claim are submitted at the same time or when an NOA and one is already in the system. If the NOA and claim were submitted at the same time, and no NOA has yet been processed for the admission period, resubmit the NOA and wait for it to process before submitting the claim. If the NOA already on the system needs to be corrected, cancel the processed NOA and after it has canceled, submit the NOA with the corrected information. Reviewed: Jul 16, 2024 |
39929 | Home Health and Hospice: Each line of charges on this claim has been rejected and/or rejected and denied. |
Rejection |
Claim Error Reason Code 39929Error Description
Home Health and Hospice: Each line of charges on this claim has been rejected and/or rejected and denied. Avoiding/Correcting This ErrorVerify the line level rejection information to determine the rejection for each of the lines of the claim in question. Providers can see line details in NGSConnex and hover over the line item reason code(s) for details. You can access MAP171D for line item detail information:
Reviewed: Jul 16, 2024 |
39934 | Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility. |
Rejection |
Claim Error Reason Code 39934Error Description
Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility. Avoiding/Correcting This ErrorYou can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:
Reviewed: Jul 16, 2024 |
U5106 | Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period. |
RTP |
Claim Error Reason Code U5106Error Description
Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period. Avoiding/Correcting This ErrorWhen the hospice NOE was received it fell within a previously established election period.
Reviewed: Jul 16, 2024 |
U5194 | Hospice: A hospice NOE with an admission date on or after 10/1/2014 must be received within five calendar days after the effective date of the hospice election. An initial hospice claim (where the from date matches the admit date) has been received where the NOE was not received timely and OSC 77 is either missing or contains invalid dates. |
RTP |
Claim Error Reason Code U5194Error Description
Hospice: A hospice NOE with an admission date on or after 10/1/2014 must be received within five calendar days after the effective date of the hospice election. An initial hospice claim (where the from date matches the admit date) has been received where the NOE was not received timely and OSC 77 is either missing or contains invalid dates. Avoiding/Correcting This ErrorIn instances where a NOE is not timely-filed, the days of hospice care from the hospice admission date to the date the NOE is submitted to and subsequently processed by the Medicare contractor will not be covered. The hospice shall report these noncovered days on the claim with an OSC 77, and charges related to the these days shall be reported as noncovered, or the claim will be returned to the provider. The noncovered days will be provider liable, and the beneficiary cannot be billed for them. A hospice may request an exception to the timely filing NOE rules which, if approved, waives the consequences of filing a NOE late. Even if a hospice believes that exceptional circumstances beyond its control are the cause of its late-filed NOE, the hospice must still file the associated claim with the OSC 77 to identify the noncovered, provider liable days. The hospice will also report a KX modifier with the site of service code (Q HCPCS codes) associated with the earliest dated level of care line on the claim along with remarks to explain the reason for the late NOE. Related ContentReviewed: Jul 16, 2024 |
U5200 | Hospice: CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
Hospice: CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorVerify that the MBI on the claim is for the correct beneficiary.
Reviewed: Jul 16, 2024 |
U5211 | Home Health and Hospice: The statement from/through date is greater than the date of death on the beneficiary master record. |
Rejection |
Claim Error Reason Code U5211Error Description
Home Health and Hospice: The statement from/through date is greater than the date of death on the beneficiary master record. Avoiding/Correcting This ErrorVerify the MBI and dates of service.
Reviewed: Jul 16, 2024 |
U5233 | Home Health: The services on this claim fall within or overlap an MA HMO enrollment period. |
Rejection |
Claim Error Reason Code U5233Error Description
Home Health: The services on this claim fall within or overlap an MA HMO enrollment period. Avoiding/Correcting This ErrorCollect all insurance information from the beneficiary when admitted to your HHA. Talk to the beneficiary about insurance changes and check CWF before billing Medicare. Many times a claim will overlap an MAO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim. Reviewed: Jul 16, 2024 |
U537F | Home Health: The From date on the HH NOA falls within an existing home health admission period. |
RTP |
Claim Error Reason Code U537FError Description
Home Health: The From date on the HH NOA falls within an existing home health admission period. Avoiding/Correcting This ErrorAlways verify billing before submitting a new NOA for a beneficiary admission. There should not already be an NOA in the system pending processing or finalized prior to submitting a new NOA for a beneficiary. HHAs should not submit multiple NOAs for same admission. Reviewed: Jul 16, 2024 |
U5600 | Hospice: The dates of service reported on this claim are a duplicate to a claim with the same dates of service that has previously processed. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5600Error Description
Hospice: The dates of service reported on this claim are a duplicate to a claim with the same dates of service that has previously processed. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorProviders should develop and implement a process to ensure that duplicate claims are not being submitted.
Reviewed: Jul 16, 2024 |
37364 | Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank. |
Rejection |
Claim Error Reason Code 37364Error Description
Home Health: The dates of service fall within the span of days between the NOA receipt date and the claim From date on TOB 32X with Statement From Date on or after 01/01/2022, the NOA receipt date is 30 or more days from the claim From date, the payment amount returned from HH Pricer is equal to zero and the PROVIDER REIM field on MAP103A is blank. Avoiding/Correcting This ErrorThere was an issue with NOAs incorrectly editing for U537F. Once the system was fixed, NOAs could be resubmitted and subsequently processed. NOAs submitted late due to this issue may have affected more than one period of care claim. All claims affected should be submitted with modifier KX appended to the HIPPS code on the 0023 revenue line and Remarks specifying the request for exception to the late NOA penalty. Reviewed: Jul 16, 2024 |
37402 | Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code. |
RTP |
Claim Error Reason Code 37402Error Description
Hospice: The TOB is equal to a hospice claim (TOB 81X or 82X) and the claim From date is greater than 4/1/1998 and the receipt date is greater than or equal to 10/1/2005 and there is no claim with TOB 81x or 82x whose Thru date is exactly one day less than this claim's From date. Also, the reason code authorization field (claim page 9) does not contain this reason code. Avoiding/Correcting This ErrorHospice – This error occurs when a claim is submitted and the previous month's claim has not been found in the system or there is a gap between Through date of the previous claim and From date on this claim. Verify dates of service submitted on claim and ensure claims have been submitted in date order (no missing months). Note that there is a workaround when submitting adjustments to claims where there is a transfer in the benefit period. Enter the "Start Date 1" in the current benefit period as the admission date on the claim rather than the admission date. This will allow all days in the period to be counted in the RHC payment calculation. When resubmitting enter remarks: "adjust due to RHC errors SE17014." Reviewed: Aug 27, 2024 |
38055 | Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. |
Rejection |
Claim Error Reason Code 38055Error Description
Home Health: This home health claim was submitted as a Medicare primary claim and contains service dates which overlap a previously submitted claim for the same provider with at least one matching revenue code. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
38200 | Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
|
Rejection |
Claim Error Reason Code 38200Error Description
Home Health and Hospice: This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
Avoiding/Correcting This ErrorThis reason code may be applied when an NOA and period of care claim are submitted at the same time or when an NOA and one is already in the system. If the NOA and claim were submitted at the same time, and no NOA has yet been processed for the admission period, resubmit the NOA and wait for it to process before submitting the claim. If the NOA already on the system needs to be corrected, cancel the processed NOA and after it has canceled, submit the NOA with the corrected information. Reviewed: Jul 16, 2024 |
39934 | Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility. |
Rejection |
Claim Error Reason Code 39934Error Description
Home Health: All revenue lines denied and one or more of the lines denote beneficiary responsibility. Avoiding/Correcting This ErrorYou can find line level information by accessing MAP171D in the FISS/DDE Provider Online System:
Reviewed: Jul 16, 2024 |
U5106 | Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period. |
RTP |
Claim Error Reason Code U5106Error Description
Hospice: Hospice NOE received to add a new election period with a start date which falls within a previously established hospice election period. Avoiding/Correcting This ErrorWhen the hospice NOE was received it fell within a previously established election period.
Reviewed: Jul 16, 2024 |
U5233 | Home Health: The services on this claim fall within or overlap an MA HMO enrollment period. |
RTP |
Claim Error Reason Code U5233Error Description
Home Health: The services on this claim fall within or overlap an MA HMO enrollment period. Avoiding/Correcting This ErrorCollect all insurance information from the beneficiary when admitted to your HHA. Talk to the beneficiary about insurance changes and check CWF before billing Medicare. Many times a claim will overlap an MAO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim. Reviewed: Jul 16, 2024 |
U537F | Home Health: The From date on the HH NOA falls within an existing home health admission period. |
RTP |
Claim Error Reason Code U537FError Description
Home Health: The From date on the HH NOA falls within an existing home health admission period. Avoiding/Correcting This ErrorAlways verify billing before submitting a new NOA for a beneficiary admission. There should not already be an NOA in the system pending processing or finalized prior to submitting a new NOA for a beneficiary. HHAs should not submit multiple NOAs for same admission. Reviewed: Jul 16, 2024 |
N5052 | The spelling of the beneficiary’s name or the beneficiary’s MBI on the claim differs from the information in the beneficiary’s master file. |
RTP |
Claim Error Reason Code N5052Error Description
The spelling of the beneficiary’s name or the beneficiary’s MBI on the claim differs from the information in the beneficiary’s master file. Avoiding/Correcting This ErrorThe beneficiary’s name listed on the claim has to be an exact match to what is posted on CWF. Be sure that any special characters (including apostrophes, dashes, commas) and suffixes (Jr., Sr., III) that are included on the Medicare file are also reflected on the claim. A beneficiary’s MBI may be updated if coverage changes. Be sure to include the updated MBI on the claim. Use CWF or NGSConnex to verify the spelling of the beneficiary's name and/or identify a logically deleted MBI. Correct claim to update beneficiary's name and/MBI and resubmit the RTP claim. was issued for Medicare contractors to return claims to provider when the name and MBI on the claim does not match what is on CWF. Related Content
Reviewed: Jul 16, 2024 |
U5065 | The MBI effective or end date is not within the dates of service submitted on the claim. |
RTP |
Claim Error Reason Code U5065Error Description
The MBI effective or end date is not within the dates of service submitted on the claim. Avoiding/Correcting This ErrorCheck/verify the beneficiary's entitlement dates in the CWF. A Medicare beneficiary, or their authorized representative, may have requested a new MBI. Verify eligibility and MBI number, correct and return the claim. Reviewed: Jul 16, 2024 |
U5065 | The MBI effective or end date is not within the dates of service submitted on the claim. |
RTP |
Claim Error Reason Code U5065Error Description
The MBI effective or end date is not within the dates of service submitted on the claim. Avoiding/Correcting This ErrorCheck/verify the beneficiary's entitlement dates in the CWF. A Medicare beneficiary, or their authorized representative, may have requested a new MBI. Verify eligibility and MBI number, correct and return the claim. Reviewed: Jul 16, 2024 |
U5109 | Hospice revocation (8XB), change of provider (8XC), void of election period (8XD) or change of ownership (8XE) does not match to a posted election period on the hospice master record for this beneficiary. |
RTP |
Claim Error Reason Code U5109Error Description
Hospice revocation (8XB), change of provider (8XC), void of election period (8XD) or change of ownership (8XE) does not match to a posted election period on the hospice master record for this beneficiary. Avoiding/Correcting This ErrorWhen submitting a transaction to indicate the beneficiary’s election to revoke the hospice benefit, transfer the patient, cancel the election, or a change of ownership, the information on the transactional bill type must match a current, open election for the beneficiary. Related ContentReviewed: Jul 16, 2024 |
U5111 | Hospice NOE received for revocation (8XB) or void of election period (8XD) and the start date on the transaction falls within a previously established hospice election period on the hospice master record for this beneficiary. |
RTP |
Claim Error Reason Code U5111Error Description
Hospice NOE received for revocation (8XB) or void of election period (8XD) and the start date on the transaction falls within a previously established hospice election period on the hospice master record for this beneficiary. Avoiding/Correcting This ErrorHospice – When submitting a hospice Notice of Termination/Revocation (TOB 8XB) or a Cancel Notice of Election (TOB 8XD) ensure that the From date on the transaction matches the Start date posted on CWF for that hospice election period. Reviewed: Jul 16, 2024 |
U5111 | Hospice: The hospice NOE or revocation (8xB) and start date matches a posted hospice election period start date current termination date and revocation indicator is other than zero. This is a duplicate revocation notice, or a claim has processed with occurrence code ‘23’ date of cancellation, or ‘42’ date of hospice revocation, which has caused the revocation information to be posted to the master record. |
RTP |
Claim Error Reason Code U5111Error Description
Hospice: The hospice NOE or revocation (8xB) and start date matches a posted hospice election period start date current termination date and revocation indicator is other than zero. This is a duplicate revocation notice, or a claim has processed with occurrence code ‘23’ date of cancellation, or ‘42’ date of hospice revocation, which has caused the revocation information to be posted to the master record. Avoiding/Correcting This ErrorThe 8xB (NOTR) transaction should only be submitted when the beneficiary revokes the hospice benefit or is discharged alive and there is no final claim in the system indicating termination of the hospice benefit. If the claim has already been filed with an occurrence code indicating the hospice benefit was terminated, the NOTR is not required. Related ContentReviewed: Jul 16, 2024 |
U5181 | Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3, occurrence code 27 is reported on the claim for the billing period in which the certification or recertification was obtained. Therefore:
|
RTP |
Claim Error Reason Code U5181Error Description
Per the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 11, Section 30.3, occurrence code 27 is reported on the claim for the billing period in which the certification or recertification was obtained. Therefore:
Avoiding/Correcting This ErrorEnsure the usage of an appropriate certification or recertification date in accordance with occurrence code 27. Related ContentReviewed: Jul 16, 2024 |
U5200 | CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
CMS’ records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorPart of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system or the FISS/DDE Provider Online System or NGSConnex to verify beneficiary eligibility prior to claim submission. Related ContentReviewed: Jul 16, 2024 |
U5200 | Inpatient services are reported on the claim and the beneficiary’s Part A coverage is not in effect; or outpatient services are reported on the claim and the beneficiary’s Part B coverage is not in effect. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
Inpatient services are reported on the claim and the beneficiary’s Part A coverage is not in effect; or outpatient services are reported on the claim and the beneficiary’s Part B coverage is not in effect. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorPart of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission. Reviewed: Jul 16, 2024 |
U5200 | CMS' records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5200Error Description
CMS' records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorPart of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS DDE Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission. Reviewed: Jul 16, 2024 |
U5210 | The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This Error Verify that the MBI on the claim is for the correct beneficiary.
Reviewed: Jul 16, 2024 |
U5210 | The claim rejected because services were provided prior to the beneficiary’s Medicare Part A or Part B entitlement date; therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The claim rejected because services were provided prior to the beneficiary’s Medicare Part A or Part B entitlement date; therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorEach beneficiary should be screened for eligibility. Part of the eligibility verification process should include ensuring the dates of service fall within the Medicare entitlement period. Use the IVR system, the FISS Provider Online System, or NGSConnex to verify beneficiary eligibility prior to claim submission. Related ContentReviewed: Jul 16, 2024 |
U5210 | The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5210Error Description
The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorVerify that the MBI on the claim is for the correct beneficiary.
Reviewed: Jul 16, 2024 |
U5220 | The services billed on the claim were provided prior to the date the beneficiary was entitled to Medicare coverage. Therefore, no Medicare payment can be made. |
Rejection |
Claim Error Reason Code U5220Error Description
The services billed on the claim were provided prior to the date the beneficiary was entitled to Medicare coverage. Therefore, no Medicare payment can be made. Avoiding/Correcting This ErrorVerify the MBI and date(s) of service. If services were provided prior to the date the beneficiary was entitled to Medicare, no further action is necessary. Otherwise, correct and resubmit. Reviewed: Jul 16, 2024 |
U5233 | The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. |
Rejection |
Claim Error Reason Code U5233Error Description
The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
U5233 | The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. |
Rejection |
Claim Error Reason Code U5233Error Description
The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. Avoiding/Correcting This ErrorVerify the admission date, from and through dates on the claim and compare the dates to the HMO entitlement dates.
Reviewed: Jul 16, 2024 |
U5233 | The services on this claim fall within or overlap an MA HMO enrollment period. |
Rejection |
Claim Error Reason Code U5233Error Description
The services on this claim fall within or overlap an MA HMO enrollment period. Avoiding/Correcting This ErrorVerify the admission date, from, and through dates on the claim and compare the dates to the MAO/HMO entitlement dates.
Reviewed: Jul 16, 2024 |
U5233 | The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. |
Rejection |
Claim Error Reason Code U5233Error Description
The services on this claim fall within or overlap an MA HMO enrollment period. For inpatient PPS claims, the admission date falls within the HMO enrollment period. Avoiding/Correcting This ErrorVerify the admission date, from, and through dates on the claim and compare the dates to the HMO entitlement dates.
Reviewed: Jul 16, 2024 |
U523A | The dates of service are during both a hospice election period and a MA plan's period that is in a VBID model. |
RTP |
Claim Error Reason Code U523AError Description
The dates of service are during both a hospice election period and a MA plan's period that is in a VBID model. Avoiding/Correcting This ErrorHospice – This reason code is a notification to the provider of a VBID patient. For more information, including calendar-year specific downloadable lists of service area plan benefit packages (PBPs) and contact information, please refer to the CMS web page, Medicare Advantage Value-Based Insurance Design Model. Claims rejected with U523A will open benefit periods in Medicare’s eligibility systems. Hospice agencies must send all notices and claims to both the participating MAO and MAC on timely basis. You must send all notices and claims to both the participating MAO and your Medicare Administrative Contractor (MAC). The MAO will process payment, and the MAC will process the claims for informational and operational purposes and for CMS to monitor the Model. If you contract to provide hospice services with the plan, be sure to confirm billing and processing steps before the calendar year begins, as they may be different. Please Note
Reviewed: Jul 16, 2024 |
34293 | Revenue code 519 is present and the beneficiary is not enrolled in a Medicare advantage plan under option code 'A', 'B', OR 'C'. |
Rejection |
Claim Error Reason Code 34293Error Description
Revenue code 519 is present and the beneficiary is not enrolled in a Medicare advantage plan under option code 'A', 'B', OR 'C'. Avoiding/Correcting This ErrorReview your beneficiary’s enrollment in a Medicare HMO/MAO prior to providing services. A beneficiary may drop MAO coverage; review the CWF, IVR, NGSConnex, or HETS to identify a termination date for the MAO plan. Related ContentReviewed: Jul 16, 2024 |
U538Q | Services billed while beneficiary is unlawfully present in the United States. |
Rejection |
Claim Error Reason Code U538QError Description
Services billed while beneficiary is unlawfully present in the United States. Avoiding/Correcting This ErrorMedicare does not pay for medical items/services furnished to an alien beneficiary who was not lawfully present in the United States on the date of service that the items/services were furnished. Related ContentCMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1 - General Billing Requirements, Section 10.5 - Claims Processing Requirements for Deported Beneficiaries Reviewed: Jul 16, 2024 |
W7062 | A claim has been submitted with an MBI; however, the MBI/HIC combination was not found on the MBI cache or CWF MBI Crosswalk. |
RTP |
Claim Error Reason Code W7062Error Description
A claim has been submitted with an MBI; however, the MBI/HIC combination was not found on the MBI cache or CWF MBI Crosswalk. Avoiding/Correcting This Error
Related ContentReviewed: Jul 16, 2024 |
W7088 | FQHC PPS TOB 77X is submitted and at least one of the specific payment codes G0466‒G0470 is not present. |
RTP |
Claim Error Reason Code W7088Error Description
FQHC PPS TOB 77X is submitted and at least one of the specific payment codes G0466‒G0470 is not present. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
W7088 | This claim was submitted for FQHC PPS reimbursement and not reported with a payment code. |
RTP |
Claim Error Reason Code W7088Error Description
This claim was submitted for FQHC PPS reimbursement and not reported with a payment code. Avoiding/Correcting This ErrorWhen submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Also be sure to report a qualifying visit HCPCS code line to indicate the services provided during the encounter, as well as any incident-to services. FQHC PPS payment codes:
Report with billable encounter revenue code:
Each payment code (encounter) line must have a corresponding service line with a HCPCS code that describes the qualifying visit. Qualifying visit HCPCS codes are found on CMS’ FQHC center website. Avoiding/Correcting This ErrorUse the claim correction option to report the payment code and coordinating qualifying visit HCPCS code and resubmit the claim for processing. Related ContentReviewed: Jul 16, 2024 |
W7089 | The claim lacks required device code or required procedure code. |
RTP |
Claim Error Reason Code W7089Error Description
The claim lacks required device code or required procedure code. Avoiding/Correcting This Error
Reviewed: Jul 16, 2024 |
W7089 | This claim was submitted for FQHC PPS reimbursement and not reported with a qualifying visit HCPCS code. |
RTP |
Claim Error Reason Code W7089Error Description
This claim was submitted for FQHC PPS reimbursement and not reported with a qualifying visit HCPCS code. When submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Each payment code (encounter) line must have a corresponding service line with a HCPCS code that describes the qualifying visit. Qualifying visit HCPCS codes are found on CMS' FQHC center website. Avoiding/Correcting This ErrorUse the claim correction option to report the payment code and coordinating qualifying visit HCPCS code and resubmit the claim for processing. Related ContentReviewed: Jul 16, 2024 |
W7090 | FQHC PPS TOB 77X one of the specific payment codes G0466‒G0470 is present with a qualifying visit but revenue codes 0519, 052x or 0900 is not present. |
RTP |
Claim Error Reason Code W7090Error Description
FQHC PPS TOB 77X one of the specific payment codes G0466‒G0470 is present with a qualifying visit but revenue codes 0519, 052x or 0900 is not present. Avoiding/Correcting This ErrorMedicare payment is reflected only on claims lines with the revenue codes as follows:
Related ContentReviewed: Jul 16, 2024 |
W7090 | FQHC PPS TOB 77X one of the specific payment codes G0466–G0470 is present with a qualifying visit but revenue code's 0519, 052X or 0900 is not present. |
RTP |
Claim Error Reason Code W7090Error Description
FQHC PPS TOB 77X one of the specific payment codes G0466–G0470 is present with a qualifying visit but revenue code's 0519, 052X or 0900 is not present. Avoiding/Correcting This ErrorWhen submitting FQHC PPS claims, report an appropriate payment code to identify the billable encounter. Also be sure to report a qualifying visit HCPCS code line to indicate the services provided during the encounter: FQHC PPS payment codes:
Report with billable encounter revenue code:
Avoiding/Correcting This ErrorUse the claim correction option to report the payment code, coordinating qualifying visit HCPCS code, and billable encounter revenue code and resubmit the claim for processing. Reviewed: Jul 16, 2024 |
W7113 | The principal diagnosis code reported is considered supplementary or an additional code and cannot be used as the principal diagnoses. A supplementary or additional diagnosis code is not allowed as a principle diagnosis code. |
RTP |
Claim Error Reason Code W7113Error Description
The principal diagnosis code reported is considered supplementary or an additional code and cannot be used as the principal diagnoses. A supplementary or additional diagnosis code is not allowed as a principle diagnosis code. Avoiding/Correcting This ErrorPrevent future similar errors by checking the I/OCE and ICD-10 official guidelines prior to claim submission. Verify the diagnosis codes reported; correct and resubmit. Related Content
Reviewed: Jul 16, 2024 |
30993 | The claim was submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. |
RTP |
Claim Error Reason Code 30993Error Description
The claim was submitted with an MBI and the MBI/HIC combination was not found on the MBI cache or CWF MBI crosswalk. Avoiding/Correcting This Error:Verify the MBI with the beneficiary and NGSConnex prior to using it on a claim. Related ContentReviewed: Jul 15, 2024 |
31191 | Home Health: TOB is equal to home health NOA 32A and Admission Date, From Date and Through date do not match. |
RTP |
Claim Error Reason Code 31191Error Description
Home Health: TOB is equal to home health NOA 32A and Admission Date, From Date and Through date do not match. Avoiding/Correcting This Error:When submitting the NOA, all date fields must match. Since the NOA is the start of the admission period, the "From" date, "Through" date and "Admission" date should all be the same. Reviewed: Jul 15, 2024 |
31197 | The claim is bill type 13X or 85X and contains condition code 89 and a 9-digit ZIP Code; however, a one-to-one cannot be made to an OTP CCN. |
RTP |
Claim Error Reason Code 31197Error Description
The claim is bill type 13X or 85X and contains condition code 89 and a 9-digit ZIP Code; however, a one-to-one cannot be made to an OTP CCN. Avoiding/Correcting This ErrorVerify that all information is keyed correctly according to the applicable entry in the SAMHSA Opioid Treatment Program directory and your Medicare Part A enrollment information. When corrections are completed, return the claim for processing. Related Content
Reviewed: Jul 15, 2024 |
31605 | Claim has occurrence code 77 with ‘From’ and ‘Through’ dates indicating non-coverage during this time. However, a line item date is present that is equal to or within this non-covered time and the charges are greater than zero.
|
RTP |
Claim Error Reason Code 31605Error Description
Claim has occurrence code 77 with ‘From’ and ‘Through’ dates indicating non-coverage during this time. However, a line item date is present that is equal to or within this non-covered time and the charges are greater than zero.
Avoiding/Correcting This ErrorThe occurrence span code 77 should only be used to indicate the span of days that were not covered on claims. Related Content
Reviewed: Jul 15, 2024 |
31836 | The HCPCS on the revenue code line has a status code of 'M', but the TOB is not equal to 85X. |
RTP |
Claim Error Reason Code 31836Error Description
The HCPCS on the revenue code line has a status code of 'M', but the TOB is not equal to 85X. Avoiding/Correcting This ErrorChange TOB to 85X. Reviewed: Jul 15, 2024 |
32078 | For the specific type of bills listed, the claim contains one or more revenue codes that are not valid for the type of bill:
All references to TOB 73X now apply to TOB 77X. |
RTP |
Claim Error Reason Code 32078Error Description
For the specific type of bills listed, the claim contains one or more revenue codes that are not valid for the type of bill:
All references to TOB 73X now apply to TOB 77X. Avoiding/Correcting This ErrorProviders can utilize the FISS DDE system and check Option 01/13 revenue code file and find the type of bill that is applicable to their claim. The system will have a “Y” or “N” indication as to whether the revenue code is allowed for the type of claim. Verify billing and if appropriate, correct. Reviewed: Jul 15, 2024 |
32078 | The claim lines contain one or more revenue codes that are not valid for type of bill 77X:
|
RTP |
Claim Error Reason Code 32078Error Description
The claim lines contain one or more revenue codes that are not valid for type of bill 77X:
Avoiding/Correcting This ErrorEnsure that your FQHC claim follows billing requirements for PPS reimbursement. Report a billable encounter revenue code (52X, 78X, or 900) on payment code lines and qualifying visit HCPCS code lines. Claim lines reporting incident-to services should be billed using non-billable encounter revenue codes. Verify billing and if appropriate, correct. Reviewed: Jul 15, 2024 |
32243 | A revenue code is present in the line item being edited, but the total charges associated with that line item are blank or equal to zero. |
RTP |
Claim Error Reason Code 32243Error Description
A revenue code is present in the line item being edited, but the total charges associated with that line item are blank or equal to zero. For claims with DOS on/after 4/1/2010, detailed line-item reporting is required. Services provided incident to the encounter should report a non billable encounter revenue code and actual charges. AIR: The claim’s encounter line revenue code should reflect a clinic visit (520), mental health visit (0900), or telehealth visit (0780) and include all charges incurred during the encounter. PPS: The claim’s encounter line revenue code should reflect a clinic visit (520) or mental health visit (0900) and include charges determined by the facility to reflect payment code charges. Avoiding/Correcting This ErrorUse claim correction option to update claim, if appropriate. Reviewed: Jul 15, 2024 |
32266 | When billing for the administration of influenza, hepatitis, or pneumococcal vaccine, you must report the HCPCS code in conjunction with revenue code 771. This applies to the administration of influenza virus vaccine HCPCS code G0008, the administration of pneumococcal vaccine HCPCS code G0009, the administration of hepatitis b vaccine HCPCS code G0010, or the Influenza A (H1N1) immunization administration HCPCS code G9141 (includes the physician counseling the patient/family). This also applies to COVID-19 vaccine administration HCPCS codes and COVID-19 Non-Administration HCPCS codes. |
RTP |
Claim Error Reason Code 32266Error Description
When billing for the administration of influenza, hepatitis, or pneumococcal vaccine, you must report the HCPCS code in conjunction with revenue code 771. This applies to the administration of influenza virus vaccine HCPCS code G0008, the administration of pneumococcal vaccine HCPCS code G0009, the administration of hepatitis b vaccine HCPCS code G0010, or the Influenza A (H1N1) immunization administration HCPCS code G9141 (includes the physician counseling the patient/family). This also applies to COVID-19 vaccine administration HCPCS codes and COVID-19 Non-Administration HCPCS codes. Avoiding/Correcting This ErrorReport influenza virus, pneumococcal pneumonia virus, and COVID-19 vaccines (and administration) with your charges on the 77X claim for informational and data collection purposes only. Report revenue code 0771 with the appropriate HCPCS/CPT code and actual charges on the claim line. The costs for these vaccines for are included in the FQHC’s cost report. Neither coinsurance nor deductible apply to either of these vaccines. Hepatitis B vaccine is included in the PPS encounter rate. The charges of the vaccine and its administration can be included on a claim for a qualifying encounter. Report revenue code 0771 with the appropriate HCPCS/CPT code and actual charges on the claim line. For any vaccination, an encounter cannot be billed if vaccine administration is the only service the FQHC provides. Related ContentReviewed: Jul 15, 2024 |
32402 | Either the CPT or HCPCS code(s) reported on this claim was not been billed with a valid revenue code for the date(s) of service. |
RTP |
Claim Error Reason Code 32402Error Description
Either the CPT or HCPCS code(s) reported on this claim was not been billed with a valid revenue code for the date(s) of service. Avoiding/Correcting This ErrorVerify HCPCS code using the FISS DDE Inquiries HCPCS file (option 14) to determine the allowable revenue codes based upon the date of service. Verify billing and, if appropriate, correct the claim using the claims correction option to report the appropriate HCPCS/CPT code and resubmit the claim to your MAC. Reviewed: Jul 16, 2024 |
32402 | Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. |
RTP |
Claim Error Reason Code 32402Error Description
Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. Avoiding/Correcting This ErrorVerify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable revenue codes will be displayed based on DOS. Use the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim. Reviewed: Jul 16, 2024 |
32402 | Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. |
RTP |
Claim Error Reason Code 32402Error Description
Either the CPT or HCPCS code reported on the claim was not billed with a valid revenue code for the DOS on the claim. Avoiding/Correcting This ErrorVerify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable revenue codes will be displayed based on DOS. Use the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim. Reviewed: Jul 16, 2024 |
32404 | Either the HCPCS code is missing from the claim (or) is not on file for one of the following reason(s):
|
RTP |
Claim Error Reason Code 32404Error Description
Either the HCPCS code is missing from the claim (or) is not on file for one of the following reason(s):
Verify HCPCS code using the FISS Inquiries HCPCS file (option 14). Allowable HCPCS codes will be displayed based on DOS. Avoiding/Correcting This ErrorUse the claims correction option to report the appropriate HCPCS/CPT code and resubmit the RTP claim. Reviewed: Jul 16, 2024 |
CO-109 | Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. |
ANSI |
Claim Error Reason Code CO-109Error Description
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. Avoiding/Correcting This ErrorThis denial is received when your Medicare patient is enrolled in a MA plan, instead of “traditional fee-for-service” Medicare. MA plans are health plans offered by private companies approved by Medicare that replaces a beneficiary's traditional Medicare plan. When actively enrolled into an MA Plan, please submit the patient's Medicare claims to that MA Plan. 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. Reviewed: Jul 15, 2024 |
CO-151 | Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. |
ANSI |
Claim Error Reason Code CO-151Error Description
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Avoiding/Correcting This ErrorThis denial message sets when a CPT/HCPCS code billed on the claim exceeded the allowed UOS under MUE rules. Under its NCCI, CMS set a standard on the number of units allowed on some CPT/HCPCS codes when billed for the same beneficiary, by the same provider, on the same date of service. These are the MUE. Most MUE values are public information and are posted to the CMS website. Some MUE values are confidential and not published. This confidentiality is subject to change. When this denial message is set, the provider should perform a review of the patient’s medical record and review the following:
Providers enrolled in NGSConnex may submit their redetermination electronically using the instructions in the NGSConnex User Guide. MUE tables are updated quarterly and posted to CMS’ website Medicare NCCI Medically Unlikely Edits | CMS There are three distinct MUE tables to identify codes subject to MUE edits.
Reviewed: Jul 15, 2024 |
CO-151 | Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. |
ANSI |
Claim Error Reason Code CO-151Error Description
Payment adjusted because the payer deems the information submitted does not support this many/frequency of services. Avoiding/Correcting This ErrorThis denial message sets when a CPT/HCPCS code billed on the claim exceeded the allowed UOS under MUE rules. Under its NCCI, CMS set a standard on the number of units allowed on some CPT/HCPCS codes when billed for the same beneficiary, by the same provider, on the same date of service. These are the MUE. Most MUE values are public information and are posted to the CMS website. Some MUE values are confidential and not published. This confidentiality is subject to change. When this denial message is set, the provider should perform a review of the patient’s medical record and review the following:
Providers enrolled in NGSConnex may submit their redetermination electronically using the instructions in the NGSConnex User Guide. MUE tables are updated quarterly and posted to CMS’ website Medicare NCCI Medically Unlikely Edits | CMS There are three distinct MUE tables to identify codes subject to MUE edits.
Reviewed: Jul 15, 2024 |
CO-16 | Missing/incomplete/invalid procedure code. |
ANSI |
Claim Error Reason Code CO-16Error Description
Missing/incomplete/invalid procedure code. Avoiding/Correcting This ErrorThe CPT/HCPCS code reported is not valid for the date(s) of service billed on the claim. This may also mean that the digits or alpha characters in the code are incorrectly reported. Please review the claim and check the status of the CPT/HCPCS code in question. Submit the claim again when you have the correct code, or the correct digits/alpha for the code. Reviewed: Jul 15, 2024 |
CO-22 | This care may be covered by another payer per coordination of benefits. |
ANSI |
Claim Error Reason Code CO-22Error Description
This care may be covered by another payer per coordination of benefits. Avoiding/Correcting This ErrorDuring patient registration, it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer. Reviewed: Jul 15, 2024 |
CO-22 | This care may be covered by another payer per coordination of benefits. |
ANSI |
Claim Error Reason Code CO-22Error Description
This care may be covered by another payer per coordination of benefits. Avoiding/Correcting This ErrorDuring patient registration it’s important for office staff to identify whether a beneficiary’s claims should be covered by other insurance before, or in addition to, Medicare. Providers shall use our self-service tools (NGSConnex/IVR) to verify patient eligibility and benefit information to assist in determining the patient’s primary insurer. Reviewed: Jul 15, 2024 |
CO-246 | This non-payable code is for required reporting only. |
ANSI |
Claim Error Reason Code CO-246Error Description
This non-payable code is for required reporting only. Avoiding/Correcting This ErrorThis is not an error. The CPT/HCPCS code reported is used for reporting purposes only. These reporting codes are given by CMS for providers to use when documenting certain incentive plans, etc. Reviewed: Jul 15, 2024 |
CO-246 | This non-payable code is for required reporting only. |
ANSI |
Claim Error Reason Code CO-246Error Description
This non-payable code is for required reporting only. Avoiding/Correcting This ErrorThis is not an error. The CPT/HCPCS code reported is used for reporting purposes only. These reporting codes are given by CMS for providers to use when documenting certain incentive plans, etc. Reviewed: Jul 15, 2024 |
CO-B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. |
ANSI |
Claim Error Reason Code CO-B7Error Description
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Avoiding/Correcting This ErrorThere is an issue with the billing and/or rendering provider credentialing information per provider enrollment, provider information submitted on the claim and/or or the services provided are not allowed per the providers specialty/credentials. This could reflect a number of possible issues. It is important to verify the information submitted on the claims and to verify the credentialing via PECOS. The following scenarios would apply:
Reviewed: Jul 15, 2024 |
CO-B7 | This provider was not certified/eligible to be paid for this procedure/service on this date of service. |
ANSI |
Claim Error Reason Code CO-B7Error Description
This provider was not certified/eligible to be paid for this procedure/service on this date of service. Avoiding/Correcting This ErrorThe billing or rendering provider NPI is not actively enrolled with Medicare on the date(s) of service billed on the claim. Please verify the provider's Medicare effective date in PECOS. If the provider shows active now, the claim may be resubmitted. If the provider is not active, please contact our Provider Enrollment call center to discuss what actions are needed to ensure the provider is properly enrolled in Medicare Part B. Jurisdiction JK: 888-379-3807 Reviewed: Jul 15, 2024 |
OA-109 | Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
|
ANSI |
Claim Error Reason Code OA-109Error Description
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Avoiding/Correcting This ErrorThis denial is received when your Medicare patient is enrolled in a MA plan, instead of “traditional fee-for-service” Medicare. MA plans are health plans offered by private companies approved by Medicare that replaces a beneficiary's traditional Medicare plan. When actively enrolled into an MA Plan, please submit the patient's Medicare claims to that MA Plan. 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. Reviewed: Jul 15, 2024 |
OA-18 | Exact duplicate claim/service. |
ANSI |
Claim Error Reason Code OA-18Error Description
Exact duplicate claim/service. Avoiding/Correcting This ErrorA duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the:
If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. This can occur even if the original claim is in a processing status waiting to be paid. It is critical that you do not resubmit another claim until you know the status of your original submission. If you haven’t received your RA, and you submit claim(s) again, you may receive the duplicate claim denial before you receive the RA for the first submission detailing the payment or denial of services. Electronic Claim Submitter Tips:
Remittance Advice Tips:
Reviewed: Jul 15, 2024 |
OA-18 | Exact duplicate claim/service. |
ANSI |
Claim Error Reason Code OA-18Error Description
Exact duplicate claim/service. Avoiding/Correcting This ErrorA duplicate claim submission occurs when a provider resubmits a claim either on paper or electronically for a single encounter and the service is provided by the same provider to the:
If more than one claim is submitted for the same item for the same date of service, the second claim will be denied as duplicate. This can occur even if the original claim is in a processing status waiting to be paid. It is critical that you do not resubmit another claim until you know the status of your original submission. If you haven’t received your RA, and you submit claim(s) again, you may receive the duplicate claim denial before you receive the RA for the first submission detailing the payment or denial of services. Electronic Claim Submitter Tips:
Remittance Advice Tips:
Reviewed: Jul 15, 2024 |
PR-31 | Patient cannot be identified as our insured. |
ANSI |
Claim Error Reason Code PR-31Error Description
Patient cannot be identified as our insured. Avoiding/Correcting This ErrorServices were denied for one or more of the following reasons:
To reduce or eliminate these types of claim denials, patient screening is vital to an office’s success in obtaining the essential information needed for correct claim submission. Office personnel should obtain additional patient information when registering patients. This can be accomplished by having your patient complete a medical information/history and insurance information form. Also, pay close attention to:
Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information. Reviewed: Jul 15, 2024 |
PR-204 | This service/equipment/drug is not covered under the patient's current benefit plan. |
ANSI |
Claim Error Reason Code PR-204Error Description
This service/equipment/drug is not covered under the patient's current benefit plan. Avoiding/Correcting This ErrorMedicare Fee-for-Service does not cover the service that has been billed for the condition. The CPT/HCPCS on the claim is not a covered Medicare service/equipment or drug. There are multiple reasons for denial which includes the following, but is not limited to:
To avoid future denials please use the following resources, as well as the most current CPT/HCPCS coding books, to verify if the code you want to bill to Medicare is a covered service:
Reviewed: Jul 15, 2024 |
PR-204 | This service/equipment/drug is not covered under the patient's current benefit plan. |
ANSI |
Claim Error Reason Code PR-204Error Description
This service/equipment/drug is not covered under the patient's current benefit plan. Avoiding/Correcting This ErrorMedicare Fee-for-Service does not cover the service that has been billed for the condition. Reviewed: Jul 15, 2024 |
PR-29 | The time limit for filing has expired. Remark Code N211 |
ANSI |
Claim Error Reason Code PR-29Error Description
The time limit for filing has expired. Remark Code N211 Avoiding/Correcting This ErrorProviders must file claims within a qualifying time limit to be eligible for Medicare reimbursement. The timely filing requirement is one calendar year after the date of service. The provider may not charge the beneficiary for the services except for deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made. CMS permits Medicare contractors to extend the time limit for filing a claim beyond one calendar year if the provider can show good cause for the delay. Reviewed: Jul 15, 2024 |
PR-31 | Patient cannot be identified as our insured. |
ANSI |
Claim Error Reason Code PR-31Error Description
Patient cannot be identified as our insured. Avoiding/Correcting This ErrorServices were denied for one or more of the following reasons:
To reduce or eliminate these types of claim denials, patient screening is vital to an office’s success in obtaining the essential information needed for correct claim submission. Office personnel should obtain additional patient information when registering patients. Usually this is accomplished by the patient completing a medical information/history and insurance information form. Pay close attention to:
Note: Utilize one of our self-service tools (NGSConnex/IVR) to obtain patient eligibility and benefit information. Reviewed: Jul 15, 2024 |
PR-50 | These are noncovered services because this is not deemed a 'medical necessity' by the payer. |
ANSI |
Claim Error Reason Code PR-50Error Description
These are noncovered services because this is not deemed a 'medical necessity' by the payer. Avoiding/Correcting This ErrorThe CPT/HCPCS code reported is not covered for the beneficiary, and the beneficiary is liable for these charges. If you have reported an incorrect code, or forgot a modifier, the claim will need to be reviewed as a reopening or a redetermination. Reviewed: Jul 15, 2024 |
PR-B9 | Patient is enrolled in a Hospice. |
ANSI |
Claim Error Reason Code PR-B9Error Description
Patient is enrolled in a Hospice. Avoiding/Correcting This ErrorWhen a Medicare beneficiary, or their authorized representative elects hospice all services related to the patient's terminal condition are handled by the hospice and not billed to Medicare Part B. If the patient requires care unrelated to their terminal condition, a Medicare provider may bill that service to Medicare, and ensure modifier GW is appended to the CPT/HCPCS code being billed. The physician who is the attending physician for the patient's hospice care may bill their claims to Medicare Part B with modifier GV appended to the CPT/HCPCS code being billed Reviewed: Jul 15, 2024 |
32072 | For home health claims (32X), the attending physician on the PECOS physician file has a termination date present and it is equal to or less than the claim from date of service. |
Denial |
Claim Error Reason Code 32072Error Description
For home health claims (32X), the attending physician on the PECOS physician file has a termination date present and it is equal to or less than the claim from date of service. Avoiding/Correcting This ErrorThe attending physician reported on your claim must be active in PECOS to be considered a valid attending physician for the home health patient. Reviewed: Jul 12, 2024 |
37236 | The covered charges or reimbursement is greater than 0, however, one of the following is true:
*Note: The first name is no longer evaluated as part of the matching criteria. Additionally, any special characters in the last name will be ignored. |
Denial |
Claim Error Reason Code 37236Error Description
The covered charges or reimbursement is greater than 0, however, one of the following is true:
*Note: The first name is no longer evaluated as part of the matching criteria. Additionally, any special characters in the last name will be ignored. Avoiding/Correcting This ErrorVerify eligibility of the attending/ordering physicians in PECOS. Print that verification and make it part of the medical record. If applicable, submit a reopen request to the Appeals Department indicating error and the correction needed. Reviewed: Jul 12, 2024 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). Avoiding/Correcting This ErrorReview coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity. When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:
To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal. Related Content
Reviewed: Jul 12, 2024 |
55H1L | According to the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less. |
Denial |
Claim Error Reason Code 55H1LError Description
According to the Medicare Hospice requirements, the information provided does not support a terminal prognosis of six months or less. Avoiding/Correcting This ErrorClinical progress notes should show evidence of a steady decline or downward trajectory in the beneficiary’s clinical status over time. Documentation should be objective, measurable and must support a life expectancy of six months or less. Beneficiaries who have improved or stabilized overtime and no longer have a reasonable expectation of a prognosis of six months or less should be discharged from the Medicare hospice benefit. There should be consistency between the certification documents and the hospice clinical progress notes. Reviewed: Jul 12, 2024 |
55H1R | The NOE is invalid because it does not meet statutory/regulatory requirements. |
Denial |
Claim Error Reason Code 55H1RError Description
The NOE is invalid because it does not meet statutory/regulatory requirements. Avoiding/Correcting This ErrorReview coverage and billing guidelines for the NOE to ensure that your NOEs are accurately billed. Related ContentReviewed: Jul 12, 2024 |
55H1R | The NOE is invalid because it does not meet statutory/regulatory requirements. |
Denial |
Claim Error Reason Code 55H1RError Description
The NOE is invalid because it does not meet statutory/regulatory requirements. Avoiding/Correcting This ErrorReview coverage and billing guidelines for the NOE to ensure that your NOEs are accurately billed. Related Content
Reviewed: Jul 12, 2024 |
55H2B | Documentation submitted does not support homebound status. |
Denial |
Claim Error Reason Code 55H2BError Description
Documentation submitted does not support homebound status. Avoiding/Correcting This ErrorEnsure the submitted documentation supports the beneficiary is confined to the home.
Related ContentReviewed: Jul 12, 2024 |
56900 | Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. |
Denial |
Claim Error Reason Code 56900Error Description
Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. Avoiding/Correcting This ErrorThis reason code can and should be prevented. When providers receive an ADR, 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 the supporting documentation that is being requested so that the timeframe for submitting the information can be met. 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. The ADR letter you received will indicate whether you have 30 days (Claim ADR) or 45 days (Medical Review ADR) to respond.
Reviewed: Jul 12, 2024 |
56900 | Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. |
Denial |
Claim Error Reason Code 56900Error Description
Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. Avoiding/Correcting This ErrorThis reason code can and should be prevented. When providers receive an ADR, 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 the supporting documentation that is being requested so that the timeframe for submitting the information can be met. 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. The ADR letter you received will indicate whether you have 30 days (Claim ADR) or 45 days (Medical Review ADR) to respond. Reviewed: Jul 12, 2024 |
56900 | Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. |
Denial |
Claim Error Reason Code 56900Error Description
Requested medical records were not received within the 45 day time limit; therefore, we are unable to determine the medical necessity of the services billed and this claim has been denied. If less than 120 days after denial notification on remittance advice, submit records to the contractor requesting records. Do not resubmit the claim. Avoiding/Correcting This ErrorThis reason code can and should be prevented. When providers receive an ADR, 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 the supporting documentation that is being requested so that the timeframe for submitting the information can be met. 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. The ADR letter you received will indicate whether you have 30 days (Claim ADR) or 45 days (Medical Review ADR) to respond. Reviewed: Jul 12, 2024 |
59130 | TOB 77X with HCPCS G0109 is present on or after the parm date. Prov Liability. NCD Rule 40.1 |
Denial |
Claim Error Reason Code 59130Error Description
TOB 77X with HCPCS G0109 is present on or after the parm date. Prov Liability. NCD Rule 40.1 Avoiding/Correcting This ErrorHCPC G0109 – Diabetes outpatient self-management training services, group (2 or more), per 30 minutes Diabetes Counseling and Medical Nutrition Services DSMT and MNT furnished by certified DSMT and MNT providers are billable visits in FQHCs when they are provided in a one-on-one, face-to-face encounter and all program requirements are met. Related ContentReviewed: Jul 12, 2024 |
7C387 | Unacceptable ICD-10 principle diagnosis code for dental services. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal. Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. |
Denial |
Claim Error Reason Code 7C387Error Description
Unacceptable ICD-10 principle diagnosis code for dental services. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal. Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. Avoiding/Correcting This ErrorDenial for dental services related to coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment. Related ContentCMS MLN Matters Publication Items and Services Not Covered Under Medicare Reviewed: Jul 12, 2024 |
7WEXC | Unacceptable ICD-10 principle diagnosis code. As submitted, this claim does not qualify for Medicare payment due to the principle diagnosis code supplied. If additional medical circumstances exist, or if there is a more specific diagnosis code, indicate the appropriate diagnosis code(s) for the claim(s) on appeal. Items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered. |
Denial |
Claim Error Reason Code 7WEXCError Description
Unacceptable ICD-10 principle diagnosis code. 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 ErrorNGS initiated edit 7WEXC, 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. Related Content
Reviewed: Jul 12, 2024 |
55H20 | Home Health: This claim was denied after review. The provider’s determination of noncoverage is correct. |
Denial |
Claim Error Reason Code 55H20Error Description
Home Health: This claim was denied after review. The provider’s determination of noncoverage is correct. Avoiding/Correcting This ErrorThis denial is based on review of a claim that was submitted as a demand bill. The charges on this claim are beneficiary liable. The beneficiary may be billed for these charges. Reviewed: Jul 12, 2024 |
39928 | Each line of charges on this claim has been denied by medical review. |
Denial |
Claim Error Reason Code 39928Error Description
Each line of charges on this claim has been denied by medical review. Avoiding/Correcting This ErrorTo access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree with the denial, you have the right to appeal. Reviewed: Jul 1, 2024 |
39928 | Each line of charges on this claim has been denied by medical review. |
Denial |
Claim Error Reason Code 39928Error Description
Each line of charges on this claim has been denied by medical review. Avoiding/Correcting This ErrorTo access the line level reason associated with this reason code providers should go to claim page (2) (MAP 1712) and F11 to MAP171D to see the line level denial codes for each line of the claim. If you disagree with the denial, you have the right to appeal. Reviewed: Jul 1, 2024 |
52MUE | All the line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an ABN. |
Denial |
Claim Error Reason Code 52MUEError Description
All the line items on the claim have units of service that are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater than the maximum allowable may not be billed to the beneficiary and this provision can neither be waived nor subject to an ABN. Avoiding/Correcting This ErrorYou have the right to submit an appeal when you believe the medical records support that the denied services were reasonable and medically necessary. Providers should review the information on the CMS website for Medically Unlikely Edits prior to claim submission. If the units rendered are in excess of the allowed units for that service, consider whether the excess units were actually rendered and billed correctly. Related ContentReviewed: Jul 1, 2024 |
52NCD | Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes. |
Denial |
Claim Error Reason Code 52NCDError Description
Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes. Avoiding/Correcting This ErrorEnsure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Providers can visit the CMS Medicare Coverage Database (MCD) to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials. Reviewed: Jul 1, 2024 |
52NCD | Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes. |
Denial |
Claim Error Reason Code 52NCDError Description
Line level reason code to indicate that the HCPCS code and a diagnosis code on the claim matched an NCD edit table list to deny codes. Avoiding/Correcting This ErrorEnsure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Providers can visit the CMS Medicare Coverage Database (MCD) to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials. Reviewed: Jul 1, 2024 |
53NCD | Line level denial to indicate that none of the diagnosis codes on the claim support medical necessity of the services. Service was denied beneficiary liable, because the modifier “GA” is present on the line or occurrence code 32 is present on the claim and modifier “GA” is not present on any claim line. |
Denial |
Claim Error Reason Code 53NCDError Description
Line level denial to indicate that none of the diagnosis codes on the claim support medical necessity of the services. Service was denied beneficiary liable, because the modifier “GA” is present on the line or occurrence code 32 is present on the claim and modifier “GA” is not present on any claim line. Avoiding/Correcting This ErrorReview coverage guidelines for the service being denied to ensure medical necessity of the services being provided to the beneficiary. Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. the diagnosis that are covered for the services provided. Related Content
Reviewed: Jul 10, 2024 |
54NCD | Line level reason code to indicate that none of the diagnosis codes on the claim support the medical necessity of the services. Service denied and the provider is liable. |
Denial |
Claim Error Reason Code 54NCDError Description
Line level reason code to indicate that none of the diagnosis codes on the claim support the medical necessity of the services. Service denied and the provider is liable. Avoiding/Correcting This ErrorReview coverage guidelines for the service being denied to ensure medical necessity of the services being provided to the beneficiary. Ensure all Medicare coverage and medical necessity requirements are met prior to billing. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis that are covered for the services provided. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials. Related ContentReviewed: Jul 1, 2024 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). Avoiding/Correcting This ErrorReview coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity. When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:
To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal. Related Content
Reviewed: Jul 1, 2024 |
55B31 | This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). |
Denial |
Claim Error Reason Code 55B31Error Description
This claim was denied after Medical Review. It was determined that the documentation needed to make payment was missing/incomplete (e.g., incomplete documentation to support therapy units billed). Avoiding/Correcting This ErrorReview coverage guidelines and patient records to determine if all appropriate documentation was sent for review that may have supported medical necessity. When you receive an ADR from National Government Services, pay particular attention to the information that is being requested which will be listed on the ADR including:
To assist with your ADR documentation preparation, a list of suggested service-specific documentation to submit is included in the ADR letter. While this is not an all-inclusive list, it can be useful for gathering the appropriate records to submit If all relevant records were not submitted and could support medical necessity, providers may consider filing an appeal. Related Content
Reviewed: Jul 1, 2024 |
55S05 | The documentation submitted supports that the services are not covered by Medicare. The beneficiary received a valid SNF ABN; thus, the beneficiary is liable for the noncovered charges on this claim. |
Denial |
Claim Error Reason Code 55S05Error Description
The documentation submitted supports that the services are not covered by Medicare. The beneficiary received a valid SNF ABN; thus, the beneficiary is liable for the noncovered charges on this claim. Avoiding/Correcting this ErrorThe SNF should ensure that SNF services that are not covered are identified. After discussion with the beneficiary and/or representative you should properly issue an ABN and bill for the noncovered services accordingly. Related Content
Reviewed: Jul 1, 2024 |
56900 | This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. |
Denial |
Claim Error Reason Code 56900Error Description
This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. Avoiding/Correcting This ErrorRegularly access claims in status locations SB6001, SB6098, or SB6099 to obtain a listing of claims for which records have not yet been received by the MAC (Medical Review Department). Look for information on the Overview of EDI Products and Services page of our website to sign up to receive ADRs electronically. Additional InformationThis reason code can be prevented. When providers receive an ADR, the provider should respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all of the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Please note that, depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity. Reviewed: Jul 1, 2024 |
56900 | This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. |
Denial |
Claim Error Reason Code 56900Error Description
This claim is denied for payment because the provider failed to submit documentation requested by the MAC via an ADR within 45 days of the ADR date. Medical Review requests documentation for various reasons by sending the provider a request for additional documentation, also known as an ADR. Each ADR has a date in the left-hand corner. If we do not receive the requested information within 45 days of that date, the claim is denied. Avoiding/Correcting This ErrorRegularly access claims in status locations SB6001, SB6098, or SB6099 to obtain a listing of claims for which records have not yet been received by the MAC (Medical Review Department). Look for information on the Overview of EDI Products and Services page of our website to sign up to receive ADRs electronically. Additional InformationThis reason code can be prevented. When providers receive an ADR, the provider should respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all of the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Please note that, depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity. Reviewed: Jul 1, 2024 |
59118 | This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery. Or One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date. |
Denial |
Claim Error Reason Code 59118Error Description
This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery. Or One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date. Avoiding/Correcting This ErrorReview reason code 59118 in the Direct Data Entry system for applicable codes. Alternatively, review the latest Change Requests/MLN® Matters articles for relevant ICD-10 updates. The most current MLN Matters article is listed in ‘Related Content’ below and includes a link to the most current coding information. File an appeal if applicable. Related Content
Reviewed: Jul 1, 2024 |
59118 | This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery. Or One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date. |
Denial |
Claim Error Reason Code 59118Error Description
This inpatient 11X claim was denied. The claim contains a valid ICD-10 procedure code for PTA of the carotid artery. However, the claim did not include a valid ICD-10 diagnosis code for PTA of the carotid artery. Or One of the valid ICD-10 procedure codes is present and ICD-10 diagnosis codes I672, Z006 and one code from the ICD-10 diagnosis code list for PTA and stenting are not all present on or after the ICD-10 eff date. Avoiding/Correcting This ErrorReview reason code 59118 in the Direct Data Entry system for applicable codes. Alternatively, review the latest Change Requests/MLN® Matters articles for relevant ICD-10 updates. The most current MLN Matters article is listed in ‘Related Content’ below and includes a link to the most current coding information. File an appeal if applicable. Related Content
Reviewed: Jul 1, 2024 |
59301 | This claim is denied for payment because this inpatient 11X claim did not include covered diagnoses and procedure code(s) as required per National Coverage Decision (NCD) 20.4 specific to “Implantable Cardioverter Defibrillators (ICDs). |
Denial |
Claim Error Reason Code 59301Error Description
This claim is denied for payment because this inpatient 11X claim did not include covered diagnoses and procedure code(s) as required per National Coverage Decision (NCD) 20.4 specific to “Implantable Cardioverter Defibrillators (ICDs). Avoiding/Correcting This ErrorTo prevent this error, ensure all Medicare coverage and medical necessity requirements are met prior to billing. Providers can visit the CMS Coverage Database to review the NCDs and LCDs to determine the diagnosis and procedure codes that are covered for the services rendered. If the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. Review the coverage and billing relevant to NCD 20.4 prior to rendering the services. Refer to resources in the “Additional Information” section below. Review the information on the Appeals tab for information related to submitting an adjustment to correct claims partially denied by automated LCD/NCD denials. Related Content
Reviewed: Jul 1, 2024 |
5WEXC | As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals. |
Denial |
Claim Error Reason Code 5WEXCError Description
As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals. Avoiding/Correcting This ErrorEnsure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. 5WEXC, based on coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage (200 KB) and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services (1 MB). A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment. Reviewed: Jul 1, 2024 |
5WEXC | As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals. |
Denial |
Claim Error Reason Code 5WEXCError Description
As submitted, this claim does not qualify for Medicare payment due to the principal diagnosis code supplied. If additional medical circumstances exist or if there is a more specific diagnosis code, indicate the appropriate diagnosis(s) for the claim on appeals. Avoiding/Correcting This ErrorEnsure all Medicare coverage and medical necessity requirements are met prior to billing. When the provider determines that Medicare will not cover the services, consider submitting the charges as noncovered. 5WEXC, based on coverage provisions in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage and the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services. A review of these regulations confirms the conclusion that most dental services and routine services are not part of the Medicare benefit. Although these services may have been paid previously, new edits may now result in the denial of services that are not covered under Medicare. NGS recommends review of our most recent policies as well as the CMS policies to assure proper coding and billing, as well as prompt and correct payment. Reviewed: Jul 1, 2024 |
5ND07 | The services are denied because the procedure and diagnosis coding requirements for bariatric surgery have not been met per National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity |
Denial |
Claim Error Reason Code 5ND07Error Description
The services are denied because the procedure and diagnosis coding requirements for bariatric surgery have not been met per National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity Avoiding/Correcting This Error
Related Content
Reviewed: Jul 1, 2024 |