Top Customer Care Telephone Inquiries

Connecticut and New York

The following chart provides a listing of the top provider customer care telephone inquiries and suggestions for locating this information. Please use the following inquiry type links to navigate to information of interest in the chart below.

Beneficiary Demographics
Claim Overlap
Coding Errors/Including Modifiers
Common Working File (CWF) Rejects
Filing/Billing Instructions
General/Other Issues
Missing/Invalid Codes
Patient Status Codes
Payment Explanation/Calculation
Provider Revalidation
Status Explanation and Resolution

Type of Inquiry	How to Locate this Information
Beneficiary Demographics	Providers can use the Med A Fiscal Intermediary Standard System (FISS)/Direct Data Entry (DDE) Provider Online System to obtain Part A and Part B information regarding beneficiaries. Once in the FISS/DDE Provider Online System, select Option 1 from the Main Menu, then Option 10, Beneficiary/CWF, from the Inquiry Menu. To view beneficiary information through this option, you must enter the beneficiary’s Health Insurance Claim number (HICN), last name and first initial, sex, and date of birth (MMDDYYYY).
Claim Overlap	Providers may use the Customer Care interactive voice response (IVR) system to access information on overlapping claims. Once a claim has been submitted and rejected for overlapping another provider’s claim, if the five-digit reason code is 38XXX, the information should be on the IVR system. For claims that have reason codes beginning with an alpha character (i.e., C or U), the Customer Care Department can tell you what provider your claim is overlapping.
Coding Errors/Including Modifiers	The National Government Services Customer Care, Provider Outreach and Education (POE), and Medical Review (MR) Departments cannot advise you on which codes to use. Because your reimbursement is often directly linked to the codes reported on your claim(s), the Centers for Medicare & Medicaid Services (CMS) requires you to determine which codes most accurately reflect the services performed. If you need coding assistance, you can seek help directly from the American Hospital Association (AHA). For instructions on how to obtain Healthcare Common Procedure Coding System (HCPCS) coding information, visit the CMS Web site at http://www.cms.gov/. For other coding questions, work with your medical records staff as they may be able to help. Assistance is often available from the coding association in your state. Transmittals may also be a good source of information. Articles pertaining to CMS transmittals are published in the What’s New section of our Web site; or, you can access them from the MLN Matters Articles section of the CMS Web site at http://www.cms.gov/MLNMattersArticles/.
Common Working File (CWF) Rejects	Rejected claims are assigned a reason code. The reason code explains the reason the claim was rejected. Reason code narratives for claims rejected may be viewed online through the FISS/DDE Provider Online System. To view the reason code narrative online: While in the claim, press <F1>/<PF1> and the system will present the reason code and narrative. Note that if multiple reason codes apply to the claim, only the first reason code will be viewable. To view the additional reason codes: While in the reason code file, type another reason code over the reason code listed and press <Enter>. To return to the claim, press <F3>/<PF3>. The reason code will provide details as to whether the provider must correct and resubmit the claim, submit an adjustment or take other action.
Filing/Billing Instructions	Formatting an adjustment bill: Change the bill type to (XX7), make sure the document control number (DCN) of the original bill appears on the adjustment bill. (Note: If submitting the adjustment through the FISS/DDE Provider Online System, the DCN will automatically be indicated on the adjustment bill.) Make the necessary changes to the claim, and remember to recalculate the total charges line if changes were made that affect the totals. Report the appropriate Claim Change Reason Code (i.e., condition code) in Form Locator (FL) 17–27 on the UB-04 claim form. If submitting the adjustment though the FISS/DDE Provider Online System, remember to include the adjustment reason code. Formatting other types of bills: Other instructions regarding formatting of bills can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75. (472 KB)
General/Other Issues	Providers may obtain general Medicare information from the National Government Services Web site or providers may wish to visit the CMS Web site at http://www.cms.gov.
Missing/Invalid Codes	Providers can use the FISS/DDE Provider Online System to obtain information and explanation on the status of a claim. Providers may make the necessary corrections based on the reason code(s) identified in the lower left-hand corner of the claim screen. To view the narrative for the first reason code: Press the <F1>/<PF1> help key. If there are subsequent reason codes: Position your cursor anywhere underneath the reason code, and then press <F1>/<PF1> to view the narrative. The CLAIMS CORRECTION submenu is where providers correct their return to provider (RTP) claims, and create adjustments (bill type XX7) and cancels (bill type XX8.)
Patient Status Codes	Patient status code describes the patient's disposition as of the through date on the claim. These codes have nothing to do with the patient’s medical condition. The patient status code is reported in FL 17 on the UB-04 claim form. A listing of patient status codes can be accessed in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75.2. (472 KB)
Payment Explanation/Calculation	If charges appear as noncovered on your remittance, check the paid claim online to determine if some lines on the claim were denied. If there were no line items denied, contact the PCC at the number designated for your state: Connecticut/New York IVR: 877-567-7205 Connecticut/New York PCC: 888-855-4356 If your remittance indicates a withhold amount, you may need to review prior remittance notices to determine if a previous claim was adjusted resulting in a Medicare payment recovery where the amount of the remit was insufficient to cover the amount of the Medicare recovery.
Provider Revalidation	All providers and suppliers who enrolled in the Medicare Program prior to March 25, 2011, are required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (ACA Section 6401a). Providers/suppliers who enrolled on or after March 25, 2011 have already been subject to this screening and need not revalidate at this time. Upon receipt of the revalidation request from your Medicare contractor, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the suspension of your Medicare payments. The easiest and quickest way to revalidate your enrollment information is by using the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) at https://pecos.CMS.hhs.gov.
Status Explanation and Resolution	Providers can use the FISS/DDE Provider Online System to obtain information and explanation on the status of a claim. To view the reason code narrative online: While in the claim, press <F1>/<PF1> and the system will present the reason code and narrative. Note that if multiple reason codes apply to the claim, only the first reason code will be viewable. To view the additional reason codes: While in the reason code file, type another reason code over the reason code listed and press <Enter>. To return to the claim, press <F3>/<PF3>. The reason code will provide details as to whether the provider must correct and resubmit the claim, submit an adjustment or take other action.

Date Last Reviewed: 7/1/2015