“Payer Only” Codes Submitted on Part A Medicare Claims

This article is to inform Part A providers of an editing change impacting claims submitted with “payer only” codes.

As of 7/3/2024, new edits cause claims to RTP when a “payer only” condition, occurrence, occurrence span, or value code is submitted on a Medicare claim that’s submitted electronically, through FISS DDE or hardcopy.

When “payer only” codes are included on claims, these new edits will result in reason code 326xx, where “x” represents a numerical or alpha character. There are different reason codes depending on which “payer only” code is submitted on the claim. “Payer only” codes can be identified within the NUBC code sets as those codes listed with a "Y" in the payer only field.

To address a current RTP’d claim, providers should determine the specific “payer only” code submitted on the claim and remove the code from the claim. This is done via the Claims Correction menu in FISS DDE (option 03 from Main Menu). Once the code is removed from the claim, resubmit/store the claim using PF9. Information about using Claims Correction can be found in the FISS DDE Provider Online Guide.

Alternatively, a brand-new claim may be submitted, leaving the incorrect claim with reason code 326xx in RTP status; the RTP claim will eventually drop off the system.

A resolution/ fix will not be created for these codes. Providers are encouraged to take action on claims receiving these reason codes without delay, as claims in RTP status are not considered as received by Medicare and are subject to timely filing limitations.

Posted 7/18/2024