Reason Code: U5233

Error 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

• Verify the admission date, from, and through dates on the claim and compare the dates to the MAO/HMO entitlement dates.
• Outpatient facilities and IPPS and IRF hospitals, or LTCH billing services within an MAO/HMO enrollment period must be submitted directly to the appropriate HMO contractor.
• Non-PPS inpatient hospital or inpatient SNF services which overlap either the effective or termination date of the MAO/HMO period will need to be split. Submit services rendered during the MAO/HMO enrollment period to the appropriate MAO/HMO contractor. Submit services rendered outside of the MAO/HMO enrollment period to the MAC.
• Verify HMO/MAO enrollment prior to claim submission by reviewing the CWF, HETS and FISS/DDE Provider Online System or NGSConnex.

Related Content

• FISS DDE Provider Online Guide, Chapter IV Inquiries Submenu (01): Beneficiary/CWF (10)
• NGSConnex User Guide
• HIPAA Eligibility Transaction System (HETS)