Appeal letter to process the out of network claim when treated on emergency

July 8, 2016, 9:40 pm

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Practice address
Po box 1234
Kenneth City FL-123456

Georgia Medicaid
Attn: Claims Department
PO Box: 7000
McRae, GA- 31055

Re: Out of state Medical Claim
Patient Name:
Insured’s Identification Number: 11107639099123
Service Date: 06/26/2010 to 07/02/2010
Call Reference#: 972217511

Dear Sir/Madam,

This is to report a claim for a service rendered in out of network state Florida. Patient was admitted in  Hospital on 06/25/2010 with acute respiratory failure which required urgent care and was referred to Dr  for an intensive consultation on 06/26/2010 and for further review till 07/02/2010. Hence we would like to request you to take the above situation into consideration and have the claims reimbursed at the earliest possible.

Herewith all supporting Medical documents are attached.

Incase of any queries or clarifications please call (407)123-4569 between 8.00 AM and 5.00 PM Monday through Friday Eastern Time.


Sincerely,

(Account Receivable- Reimbursement Specialist)

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Provider appeal letter when payment made to facility

July 8, 2016, 9:40 pm

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Practice address

PO BOX 123
Kenneth City FL1234
Phone#123-456-789
_______________________________________________________________________
05/10/2010

Careplus
Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634


Re: Appeal of Medical Claim
Patient Name: 
Health Insurer Identification Number: 9958002012111
Claim Number: 911204441611
Call Reference Number: 91111365797111
Service Date: 10/13/2009


Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that was denied on 12/08/2009 as "Global payment made to Facility for this service. Seek reimbursement for professional fees from facility appropriately."

We feel these charges should be allowed for the following reason(s):

• Dr.X  is the only Physician who interpreted the service (Professional component only) performed at  Outpatient Hospital on  10/13/2009. Hence Dr.X is due and eligible to get paid for the professional
services that he had rendered.

•  Hospital has billed Careplus for a global procedure in error. This facility only performed the technical component.

Now we are requesting you to reconsider our claim, reverse the payment of professional component from the other group and reimburse Dr. for the same.

When we had a discussion with the Careplus customer service, the representative advised us to file an appeal with supporting medical documents. Herewith I have attached the Claim form, Dr. X Intrepretation document and Careplus EOB.

Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.

Sincerely,

(Account Receivable – Reimbursement Specialist)

Reviewing DX with PCP which was denied for pre - exisiting

July 9, 2016, 12:34 am

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Practice address

Phone# 407-123-45678
______________________________________________________________________________________
05/28/2010
Dr.
Attn: Ayse
Address here
FL 33713-8723
Re: Request to re-view the diagnosis codes whether falls under pre-existing period.

Patient Name :
Primary Carrier : BCBS
Health Insurer Identification Number : HOSPH41862466

Dear Sir/Madam:
This is to bring to your kind attention that BCBS denied the above mentioned patient’s claims for pre-existing condition information hence we would like to request you to review the diagnosis codes mentioned below in order to determine if any of these codes fall under the waiting period.
The diagnoses are:
491.20, 518.82, 786.52, 511.9, 486, 510.9, 496, 510.9, 786.09, and 780.53……..
Thank you for reviewing and assisting us in reversal of this claim denial. If you require any
additional Information, please contact me at 407-745-1849 between the hours of 8:00 a.m and 5:00 p.m.

Sincerely,
Henry Samuel
(Account Receivable – Reimbursement Specialist)

CLIA related denials – CO-B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service & CO-18 – Duplicate service

July 10, 2016, 11:16 pm

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CLIA: Laboratory Tests

Denial Reason, Reason/Remark Code(s): 

•CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service
•CPT codes include 82947 and 85610


Resolution 

•HCPCS modifier QW must be submitted with certain clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) determines which laboratory tests are waived.
•Note: Not all CLIA-waived tests require HCPCS modifier QW
•Determine if the CPT code is a waived test by accessing the CMS CLIA Web page
•Palmetto GBA will publish information on tests newly classified as 'waived' on our website. Please note, the list of CLIA-waived procedures is updated as often as quarterly.
•The CLIA certificate number is also required on claims for CLIA waived tests. Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.
•Access complete instructions for correctly submitting HCPCS modifier QW in the Palmetto GBA Modifier Lookup tool.

Clinical Laboratory Procedures: Duplicate Denials

Denial Reason, Reason/Remark Code(s) 
•CO-18 - Duplicate Service(s): Same service submitted for the same patient
•CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610

Resolution/Resources
First: Verify the status of your claim before resubmitting. Use the Palmetto GBA Online Provider Services (OPS) tool or call the Palmetto GBA Interactive Voice Response (IVR) unit.
•All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
•Access the introductory article to learn more by selecting the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages
•Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
•Billing services and clearinghouses should contact their provider clients to gain access to the system
•Specific instructions for accessing claim status information through OPS are available in the OPS User Manual
CPT modifier 91 may be submitted to identify an identical laboratory test for the same patient on the same date.
•This modifier may not be submitted when tests are rerun to confirm initial results due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required
•This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests)
•For clinical laboratory tests ordered by an ESRD facility: these tests must be submitted with CPT modifier 91 if any single service (same CPT code) is ordered for the same patient, and the specimen is collected more than once in a single day, and the service is medically necessary
oCPT modifier 91 must be submitted with services that meet these criteria, regardless of whether the test is also submitted with HCPCS modifiers CD, CE or EF
oAny line item on a claim that meets these criteria and is submitted with CPT modifier 91 will be included into the calculation of the 50/50 rule
oAfter calculation of the 50/50 rule, services used to determine the payment amount may not exceed 22

Medicare rejection CO 24 - covered by Advantage plan

July 13, 2016, 2:46 am

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 We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.

• Medicare claims must be submitted to the MA plan.

• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.

• Obtain eligibility and benefit information prior to rendering services to patients.

• Ask patients if they have recently enrolled in any new health insurance plans.

• Request to see a copy of all of their health insurance cards.

• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify the beneficiary's eligibility prior to submitting claims to First Coast.
• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).

• Claims that are returned as unprocessable cannot be appealed, for more information click here.
End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/index.html

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.

CLIA Certification Number Required MA 120, MA 130

July 15, 2016, 11:17 pm

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Remark Code/ Message Number

•MA120: Missing/incomplete/invalid CLIA certification number
•MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Resolution 
•Entities that perform clinical laboratory tests must obtain certification through the state department of health. This is known as Clinical Laboratory Improvement Amendments of 1998 (CLIA) certification.
•Your CLIA number must be submitted on claims for clinical laboratory tests, including tests that are classified as 'CLIA-waived.' Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.
oSome clinical laboratory tests must also be submitted with HCPCS modifier QW. The Food and Drug Administration (FDA) determines which laboratory tests are waived. Please note that not all CLIA-waived tests require HCPCS modifier QW.
•Determine if the CPT code is a waived test by accessing the Centers for Medicare & Medicaid (CMS) CLIA Web page
•Palmetto GBA will publish information on tests newly classified as 'waived' on our website
•Submit your corrected claim as a new claim. Claims that are missing required CLIA certification numbers are rejected as 'billing errors' and must be submitted as new claims.

CLIA Background

•CMS regulates laboratory testing through CLIA. The primary objective of the CLIA program is to ensure quality laboratory testing. CLIA regulations require facilities to be appropriately certified for each test they perform.

•CLIA requires all facilities that perform even one test, including waived tests, on materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of human beings to meet certain Federal requirements

•Any facility that performs tests for these purposes, including physician office laboratories, are considered laboratories under CLIA and must apply for and obtain a certificate from the CLIA program

•New waived tests are approved by the FDA on a flow basis, and the tests are valid as soon as they are approved

•Generally, CLIA certification is required for each location where testing is performed. There are exceptions for laboratories that are not at a fixed location and laboratories within a hospital.

What is Member Grievances

July 18, 2016, 12:06 am

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Member Grievances

Members have the right to file a complaint if they have concerns or problems related to their coverage or care. Appeals and grievances are two different types of member complaints.

** A Part C grievance is any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

 ** In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.

 ** A Part D grievance is any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

Tufts Medicare Preferred HMO and its network providers must not treat members unfairly or discriminate against them because they initiate a complaint.

Member Grievance Procedure

July 20, 2016, 12:07 am

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Per regulatory guidelines and as part of the Tufts Health Plan commitment to ensuring member satisfaction, we have established a forum for members or authorized representatives to express concerns regarding their experiences with health care providers. The member grievance procedure, allows for the documentation and review of member complaints, as follows:

1. Upon receipt of a verbal or written complaint, the grievance specialist acknowledges either verbally or in writing that the complaint was received and will be reviewed within 30 calendar days or within 24 hours if the grievance is expedited. All grievances pertaining to clinical care and/or services issues are reviewed within the Clinical Quality Improvement (CQI) department. All grievances pertaining to provider billing, along with operations and activities of the Plan are reviewed within the Appeals and Grievances (A&G) department. The CQI and A&G department can accept any information or evidence concerning the grievance orally or in writing.

2. In most instances, providers or their office managers (depending on the specific situation) are notified either verbally or in writing about the complaint and asked for input.

3. If the complaint pertains to a quality of care issue (clinical grievance), the clinical review team evaluates the information. The grievance is assigned a rating for degree of severity and preventability of the issue of concern. The provider is generally notified of the results of the review. All grievances and their respective ratings are entered into our secured quality database for tracking and trending purposes. This data becomes part of the provider’s credentialing file and is reviewed periodically.
It is the member’s responsibility to notify Tufts Health Plan Medicare Preferred of concerns about his/her health care services. It is the responsibility of all network providers to participate in our grievance review process.

Providers are expected to respond to a request for information within five business days, as it is standard for providers to respond to the plan’s request for information in investigating member grievances. This turnaround time is required to ensure that the plan meets its regulatory and accreditation requirements to the member and remains compliant with all state and federal (CMS) requirements.

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What is Livanta and QIO

July 23, 2016, 12:08 am

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Quality Improvement Organization Complaint Process

For Tufts Medicare Preferred HMO members concerned about the quality of the care received can also file a complaint with Livanta at 866.815.5440. Quality Improvement Organizations (QIO), such as Livanta, are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. Livanta Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Massachusetts. The Livanta review process is designed to help prevent any improper practices. This process is separate and distinct from the Tufts Medicare Preferred HMO grievance (complaint) process.  

The QIO is under contract to the CMS to conduct medical reviews and other functions with respect to Medicare beneficiaries.


Livanta

Livanta is responsible for the quality of care review of services provided to Massachusetts Medicare patients enrolled in Medicare Advantage products with CMS. This includes Tufts Medicare Preferred HMO members.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended by the Omnibus Budget Reconciliation Act (OBRA) of 1986, requires Tufts Health Plan to participate in an external review of its QI program for members enrolled in Tufts Medicare Preferred HMO. The responsibilities of each organization that conducts the external review of the Tufts Medicare Preferred HMO plan are delineated in the Tufts Health Plan/Livanta agreement.




Livanta Reviews

Livanta maintains a review system to ensure that services provided to Medicare beneficiaries enrolled in Medicare health plans are of adequate quality across all settings. This review system addresses the following issues:

** Appropriateness of treatment

** Potential for under-utilization of services

** Accessibility to services

** Potential for premature discharge of patients

** Timeliness of services provided

** Appropriateness of the setting for the provision of services

** Appropriateness of the Medicare health plan’s activities to coordinate care, such as the adequacy of discharge planning and follow-up of abnormal diagnostic studies
Livanta will notify Tufts Health Plan Medicare Preferred regarding issues that include results of Livanta’s review activities, unless otherwise specified in the Livanta/CMS contract. These issues will be identified as Quality of Care concerns or documentation concerns.

Tufts Health Plan Medicare Preferred will be notified when a Livanta review indicates a quality problem regarding an out-of-plan emergency or urgently needed care that an out-of-plan hospital, skilled nursing facility (SNF), or other health care facility provided to a Tufts Medicare Preferred HMO member, and the problem is attributable to the institution. However, the quality problem identified with respect to these services will be attributed to the out-of-plan provider/practitioner, rather than to Tufts Health Plan Medicare Preferred.

M25, M26, M27 and 54 - Co surgeon denial codes

July 26, 2016, 11:27 pm

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Beneficiary Liability on Denied Claims for Assistant, Co- surgeon and Team Surgeons

MSN message 23.10 which states “Medicare does not pay for a surgical assistant for this kind of surgery,” was established for denial of claims for assistant surgeons. Where such payment is denied because the procedure is subject to the statutory restriction against payment for assistants-at-surgery. Carriers include the following statement in the MSN:

"You cannot be charged for this service.” (Unnumbered add-on message.)

Carriers use Group Code CO on the remittance advice to the physician to signify that the beneficiary may not be billed for the denied service and that the physician could be subject to penalties if a bill is issued to the beneficiary.

If Field 23 of the MFSDB contains an indicator of “0” or “1” (assistant-at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.

For those procedures with an indicator of “0,” the limitation on liability provisions described in Chapter 30 apply to assigned claims. Therefore, carriers include the appropriate limitation of liability language from Chapter 21. For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity.

Where payment may not be made for a co- or team surgeon, use the following MSN message (MSN message number 15.13):

Medicare does not pay for team surgeons for this procedure.

Where payment may not be made for a two surgeons, use the following MSN message (MSN message number 15.12):

Medicare does not pay for two surgeons for this procedure.

Also see limitation of liability remittance notice REF remark codes M25, M26, and M27.

Use the following message on the remittance notice:

Multiple physicians/assistants are not covered in this case. (Reason code 54.)

Service provided by excluded, opt out physician - denial

July 29, 2016, 3:19 am

≫ Next: The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to:

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Services provided by a Medicare sanctioned/excluded provider. No Medicare payment may be made.


Opt-Out physicians and practitioners:

Medicare payment may be made for the claims submitted by a beneficiary for the services of an opt out physician or practitioner when the physician or practitioner did not privately contract with the beneficiary for services that were not emergency care services or urgent care services and that were furnished no later than 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare (see 42 C.F.R. 405.435(c)). Therefore, if the beneficiary submits a claim for a service that was furnished by an opt out physician or practitioner, then the carrier must contact the opt out physician or practitioner in order to ascertain whether the beneficiary entered into a private contract with the opt out physician or practitioner. (Note: The carrier should obtain a copy of the private contract from the opt out physician/practitioner before denying the beneficiary’s claim if the beneficiary did, in fact, enter into a private contract with the physician or practitioner.) If the beneficiary did not enter into a private contract with the physician or practitioner and the beneficiary did not receive notice from the carrier that the physician opted out of Medicare, then Medicare payment may be made to the beneficiary for the non-emergency and/or non-urgent care services (assuming that the services would otherwise be payable). On the other hand, if the beneficiary did enter into a private contract with the physician or practitioner for the services or received services from the physician/practitioner 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare, then no Medicare payment may be made. Medicare has instructed opt out physicians and practitioners that private contract language must include beneficiary instruction precluding the beneficiary from billing Medicare for these services. An example of language that may be considered:



English

Claim denied because services were provided by an Opt-Out physician or practitioner. No Medicare payment may be made.



Contractors shall maintain documentation of beneficiary complaints involving violations of the mandatory claims submission policy and a list of the top 50 violators, by State, of the mandatory claim submission policy.

Contractors are encouraged to educate providers and suppliers that they must be enrolled in the Medicare program before they submit claims for services furnished or supplied to any Medicare beneficiary.

The above policy, including the NPI requirement, is not applicable for foreign beneficiary claims submitted for covered services. These claims should be processed using guidelines for foreign claims.

The above policy, including the NPI requirement, is not applicable to beneficiary claims submitted to DMEMACs for durable medical equipment, prosthetics, orthotics, and supplies. These claims should be processed by DMEMACs using current procedures.

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to:

August 3, 2016, 3:24 am

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 Definition of Clean Claim

A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.

The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);

• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;


• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;

• Are developed on a postpayment basis; and,

• Have all basic information necessary to adjudicate the claim, and all required supporting documentation

C. Bills Returned to Provider

If the carrier or FI returns the bill and retains a claim record to minimize data entry cost when returned, the receipt date is corrected when the bill is properly completed and passes carrier or FI edits.

D. Bills Requiring Medical Information

   

When a carrier or FI requests medical documentation, it retains the bill as a pending record until it either pays, denies, or rejects (in the case of FIs) it. Returning cases for review by the PRO is not a request for medical documentation. Claims that fail initial carrier or FI edits because required medical reports or other required attachments are not included are also not requests for medical documentation.

E. Adjustment and Cancel Bills

An adjustment request bill is a correction to a claim previously processed. The carrier or FI establishes a control record for it.

The carrier or FI counts adjustments as received and pending only when they pass carrier or FI edits. The carrier or FI assigns the date received in its mailroom as the receipt date for hospital and MSP adjustment requests.

The carrier or FI counts adjustment bills as processed when no further action by it is required. The final action taken on the adjustment request bill depends upon the situation.

Claims Receipt date

August 7, 2016, 3:25 am

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 Receipt Date

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to: determine if the claim was timely filed (see §70.3), determine the “payment floor” for the claim (see §80.2.1.2), determine the “payment ceiling” on the claim (see §80.2.1.1) and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.

A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date. A paper claim that is received after 5:00 p.m., or after the contractor’s routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.

A paper claim is considered as received if it is delivered to the contractor’s place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractor’s place of business by its routine close of business time. If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box site.

As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.

Electronic claims transmitted directly to a contractor, or to a clearinghouse with which the contractor contracts as its representative for the receipt of its claims, by 5:00 p.m. in the contractor’s time zone, or by its closing time if it routinely closes between 4:00 p.m. and 5:00 p.m., must likewise be considered as received on that day even if the contractor does not upload or process the data until a later date. NOTE: The differentiation between HIPAA-compliant and HIPAA-non-compliant electronic claims that is specified in §80.2.1.2 with respect to applying the payment floor, does not apply to establishing date of receipt. Use the methodology described above to establish the date of receipt for all electronic claims.

Paper and electronic claims that do not meet the basic legibility, format, or completion requirements are not considered as received for claims processing and may be rejected from the claims processing system. Rejected claims are not considered as received until
resubmitted as corrected, complete claims. The contractor may not use the data entry date, the date of passage of front-end edits, the date the document control number is assigned, or any date other than the actual calendar date of receipt as described above to establish the official receipt date of a claim.

The following permissive exception applies to establishment of receipt date: Where its system or hours of operation permit, a contractor may, at its option, classify a paper or electronic claim received between its closing time and midnight, or on a Saturday, Sunday, holiday, or during an emergency closing period as received on the actual calendar date of delivery or receipt. Unless a contractor closes its place of business early in an isolated situation due to an emergency, the contractor’s cutoff time for establishing the receipt date may never be earlier than 4:00 p.m.

A contractor may not make system changes, extend its hours of operation, or incur significant additional costs solely to begin to accommodate late receipt of claims if not already equipped to do so.

The cutoff time for paper claims may not exceed the cutoff time for electronic claims. However, the cutoff time for electronic claims may exceed the cutoff time for paper claims and, indeed, carriers and FIs are encouraged to use this tool where their system and overnight batch run schedules permit. Likewise, at a carrier or FI’s option, it may consider electronic claims received on a weekend or holiday as received on the actual calendar date of receipt, even though paper claims received in a P.O. box on a weekend or holiday would not be considered received until the next business day.

Where a carrier or FI prepares bills for payment for purchased DME because the $50 tolerance is exceeded (see §40.4.1) it establishes any date consistent with its system processing requirements as the receipt date for the second and succeeding bills. It uses the date as close to its payment as possible.

Understanding Medicare payment floor

August 14, 2016, 3:28 am

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Payment Floor Standards

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a made.
. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology.

Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.


Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                                     Payment Floor Date


10-01-93 through 6/30/0414th day for EMC 27th day for paper claims

07-01-04 and later14th day for HIPAA-compliant EMC  27th day for paper and non-HIPAA EMC

01/01/2006 and later29th day for paper



Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: “no-payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.

NOTE: The basis for treating a non-HIPAA-compliant electronic claim as a paper claim for the purpose of determining the applicable payment floor is as follows: Effective October 16, 2003, HIPAA requires that claims submitted to Medicare electronically comply with standard claim implementation guides adopted for national use under HIPAA. A claim submitted via direct data entry (DDE), if DDE is supported by the contractor is considered to be a HIPAA-compliant electronic claim. A contingency plan has been approved to enable claims to continue to be submitted temporarily after October 15, 2003 in a pre-HIPAA electronic format supported by Medicare. Effective July 1, 2004, the Medicare contingency plan is being modified to encourage migration to HIPAA formats. Effective July 1, 2004, for purposes of the payment floor, only those claims

 submitted in a HIPAA-compliant format will be paid as early as the 14th day after the date of receipt. Claims submitted on paper after July 1, 2004 will not be eligible for payment earlier than the 27th day after the date of receipt. All claims subject to the 27-day payment floor, including non-HIPAA electronically submitted claims, are to be reported in the paper claims category for workload reporting purposes. Effective January 1, 2006, paper claims will not be eligible for payment earlier than the 29th day after the date of receipt.

This differentiation in treatment of HIPAA-compliant and non-HIPAA-compliant electronic claims does not apply to Contractor Performance Evaluation (CPE) reviews of carriers and FIs conducted by CMS. For CPE purposes, carriers and FIs must continue to process the CPE specified percentage of clean paper and clean electronic (HIPAA or non-HIPAA) claims within the statutorily specified timeframes. Effective for claims received January 1, 2006 and later, clean paper claims will no longer be included in CPE scoring for claims processing timeliness.

How insurance handling incomplete or invalid claims

August 17, 2016, 10:34 pm

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Handling Incomplete or Invalid Claims

Claims processing specifications describe whether a data element is required, not required, or conditional (a data element which is required when certain conditions exist). The status of these data elements will affect whether or not an incomplete or invalid claim (hardcopy or electronic) will be "returned as unprocessable" or “returned to provider” (RTP) by the carrier or FI, respectively. The carrier or FI shall not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.

If a data element is required and it is not accurately entered in the appropriate field, the carrier or FI returns the claim to the provider of service.

• If a data element is required, or is conditional (a data element that is required when certain conditions exist) and the conditions of use apply) and is missing or not accurately entered in its appropriate field, return as unprocessable or RTP the claim to either the supplier or provider of service.

NOTE: Effective for claims with dates of service (DOS) on or after the implementation date of the ordering and referring phase 2 edits, Part B clinical lab and imaging technical or global component claims, Durable Medical Equipment, Prosthetics, claims and Home Health Agency (HHA) claims shall be denied, in accordance with CMS-6010-F final rule published on April 24, 2012, if the ordering or referring provider’s information is invalid or if the provider is not of a specialty that is eligible to order and refer.

• If a claim must be returned as unprocessable or RTP for incomplete or invalid information, the carrier or FI must, at minimum, notify the provider of service of the following information:

o Beneficiary’s Name;

o Claim Number; HIC Number or HICN or Health Insurance Claim Number. This has never been HI Claim Number.

o Dates of Service (MMDDCCYY) (Eight-digit date format effective as of October 1, 1998);

o Patient Account or Control Number (only if submitted);

o Medical Record Number (FIs only, if submitted); and

o Explanation of Errors (e.g., Remittance Advice Reason and Remark Codes)

NOTE: Some of the information listed above may in fact be the information missing from the claim. If this occurs, the carrier or FI includes what is available.

Depending upon the means of return of a claim, the supplier or provider of service has various options for correcting claims returned as unprocessable or RTP for incomplete or invalid information. They may submit corrections either in writing, on-line, or via telephone when the claim was suspended for development, or submit as a “corrected” claim or as an entirely new claim if data from the original claim was not retained in the system, as with a front-end return, or if a remittance advice was used to return the claim. The chosen mode of submission, however, must be currently supported and appropriate with the action taken on the claim.

NOTE: The supplier or provider of service must not be denied any services (e.g., modes of submission or customer service), other than a review, to which they would ordinarily have access.

• If a claim or a portion of a claim is “returned as unprocessable” or RTP for incomplete or invalid information, the carrier or FI does not generate an MSN to the beneficiary.

• The notice to the provider or supplier will not contain the usual reconsideration notice, but will show each applicable error code or equivalent message.

• If the carrier or FI uses an electronic or paper remittance advice notice to return an unprocessable claim, or a portion of unprocessable claim:

1. The remittance advice must demonstrate all applicable error codes. However, there must be a minimum of two codes on the remittance notice (including code Remittance Advice Remark Code : MA130).

2. The returned claim or portion must be stored and annotated, as such, in history, if applicable. If contractors choose to suspend and develop claims, a mechanism must be in place where the carrier or FI can re-activate the claim or portion for final adjudication.



A. Special Considerations

• If a “suspense” system is used for incomplete or invalid claims, the carrier or FI will not deny the claim with appeal rights if corrections are not received within the suspense period, or if corrections are inaccurate. The carrier must return the unprocessable claim through the remittance process, without offering appeal rights, to the provider of service or supplier. The FI uses the RTP process.

For assigned and unassigned claims submitted by beneficiaries (Form CMS-1490S), that are incomplete or contain invalid information, contractors shall manually return the claims to the beneficiaries. If the beneficiary furnishes all other information but fails to supply the provider or supplier’s NPI, and the contractor can determine the NPI using the NPI registry, the contractor shall continue to process and adjudicate the claim. If the contractor determines that the provider or supplier was not a Medicare enrolled provider with a valid NPI, the contractor shall follow previously established procedures in order to process and adjudicate the claim.

Contractors shall send a letter to the beneficiary with information explaining which information is missing, incorrect or invalid; information explaining the mandatory claims filing requirements; instructions for resubmitting the claim if the provider or supplier refuses to file the claim, or enroll in Medicare, and shall include language encouraging the beneficiary to seek non-emergency care from a provider or supplier that is enrolled in the Medicare program. Contractors shall also notify the provider or supplier about his/her obligation to submit claims on behalf of Medicare beneficiaries and that providers and suppliers are required to enroll in the Medicare program to receive reimbursement.

Contractors shall consider a complete claim to have all items on the Form CMS-1490S completed along with an itemized bill with the following information: date of service, place of service, description of each surgical or medical service or supply furnished; charge for each service; treating doctor’s or supplier’s name and address; diagnosis code; procedure code and the provider or supplier’s NPI. Required information on a claim must be valid for the claim to be considered as complete.

If a beneficiary submits a claim on the Form CMS-1500, return the Form CMS-1500 claim to the beneficiary, and include a copy of the Form CMS-1490S, along with a letter instructing the beneficiary to complete and return the Form CMS-1490S for processing within the time period prescribed in §70.5 above. Include in the letter a description of missing, invalid or incomplete items required for the Form CMS-1490S that were not included with the submitted Form CMS-1500 or were invalid.



NOTE: Telephone inquiries are encouraged.

• The carrier or FI shall not return an unprocessable claim if the appropriate information for both “required” and “conditional” data element requirements other than an NPI when the NPI is effective is missing or inaccurate but can be supplied through internal files. Contractors shall not search their internal files to correct missing or inaccurate “required” and “conditional” data elements required under Sections 80.3.2.1.1 through 80.3.2.1.3 and required for HIPAA compliance for claims governed by HIPAA.

• For either a paper or electronic claim, if all “required” and “conditional” claim level information that applies is complete and entered accurately, but there are both “clean” and “dirty” service line items, then split the claim and process the “clean” service line item(s) to payment and return as unprocessable the “dirty” service line item(s) to the provider of service or supplier. NOTE: This requirement applies to carriers only.

No workload count will be granted for the “dirty” service line portion of the claim returned as unprocessable. The “clean” service line portion of the claim may be counted as workload only if it is processed through the remittance process. Contractors must abide by the specifications written in the above instruction; return the “dirty” service line portion without offering appeal rights.

• Workload will be counted for claims returned as unprocessable through the remittance process. Under no circumstances should claims returned as unprocessable by means other than the remittance process (e.g., claims returned in the front-end) be reported in the carrier or FI workload reports submitted to CMS. The carrier or FI is also prohibited from moving or changing the action on an edit that will result in an unprocessable claim being returned through the remittance process. If the current action on an edit is to suspend and develop, reject in the front or back-end, or return in the mailroom, the carrier or FI must continue to do so. Workload is only being granted to accommodate those who have edits which currently result in a denial. As a result, workload reports should not deviate significantly from those reports prior to this instruction.


NOTE: Rejected claims are not counted as an appeal on resubmissions.

B. Special Reporting of Unprocessable Claims Rejected through the Remittance Process (Carriers Only):

Carriers must report “claims returned as unprocessable on a remittance advice” on line 15 (Total Claims Processed) and on line 14 (subcategory Non-CWF Claims Denied) of page one of your Form CMS-1565. Although these claims are technically not denials, line 14 is the only suitable place to report them given the other alternatives. In addition, these claims should be reported as processed “not paid other” claims on the appropriate pages (pages 2-9) of CROWD Form T for the reporting month in which the claims were returned as unprocessable through the remittance process. Also, carriers report such claims on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) system. They report the “number of such claims returned during the month as unprocessable through the remittance process” under Column 1 of Form Y on a line using code “0003” as the identifier.

If a supplier, physician, or other practitioner chooses to provide missing or invalid information for a suspended claim by means of a telephone call or in writing (instead of submitting a new or corrected claim), carriers do not report this activity as a claim processed on Form CMS-1565/1566. Instead, they subtract one claim count from line 3 of Form Y for the month in which this activity occurred.

EXAMPLE: Assume in the month of October 2001 the carrier returned to providers 100 claims as unprocessable on remittance advices. The carrier should have included these 100 claims in lines 14 and 15 of page 1 of your October 2001 Form CMS-1565. During this same month, assume the carrier received new or corrected claims for 80 of the 100 claims returned during the month. These 80 claims should have been counted as claims received in line 4 of your October 2001 Form CMS-1565 page one (and subsequently as processed claims for the reporting month when final determination was made).

Also, during October 2001, in lieu of a corrected claim from providers, assume the carrier received missing information by means of a telephone call or in writing for 5 out of the 100 claims returned during October 2001. This activity should not have been reported as new claims received (or subsequently as claims processed when adjustments are made) on Form CMS-1565. On line 3 of Form Y for October 2001, the carrier should have reported the number 95 (From claims returned as unprocessable through the remittance process minus 5 claims for which the carrier received missing or invalid information by means of a telephone call or in writing.

For the remaining 15 claims returned during October 2001 with no response from providers in that same month, the carrier should have reported on the Form CMS-1565 or Form Y, as appropriate, any subsequent activity in the reporting month that it occurred. For any of these returned claims submitted as new or corrected claims, the carrier should have reported their number as receipts on line 4 of page one of Form CMS-1565. For any of these returned claims where the supplier or provider of service chose to supply missing or invalid information by means of a telephone call or in writing, the carrier should not have counted them again on Form CMS-1565, but subtracted them from the count of returned claims reported on line 3 of Form Y for the month this activity occurred.


C. Exceptions (Carrier Only)

The following lists some exceptions when a claim may not be “returned as unprocessable” for incomplete or invalid information.
Carriers shall not return a claim as unprocessable:

If a patient, individual, physician, supplier, or authorized person’s signature is missing, but the signature is on file, or if the applicable signature requirements have been met, do not return a claim as unprocessable where an authorization is attached to the claim or if the signature field has any of the following statements (unless an appropriate validity edit fails):

Acceptable Statements for Form CMS-1500:

• For items 12, 13, and 31, “Signature on File” statement and/or a computer generated signature;

• For items 12 and 13, Beneficiary’s Name “By” Representative’s Signature;

For item 12, “X” with a witnessed name and address. (Chapter 26 for instructions.)

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Preventing duplicate claim denials - with example

August 20, 2016, 10:52 pm

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Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and/or modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. (An example is listed below.) In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.


Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate. Please review the Current Procedural Terminology (CPT®) codebook for a complete list of modifiers.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances.

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59. Refer to MLN Matters® article MM8863 external pdf file for details.
• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.
• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT® code 82948).
Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

• Modifiers RT (right side) and LT (left side): Append applicable modifier to the procedure code, even if the diagnosis indicates the exact site of the procedure.

• Example: Provider submits Medicare claim for diagnosis code M1711 (unilateral primary osteoarthritis, right knee) and/or diagnosis code M1712 (unilateral primary osteoarthritis, left knee). Modifier RT should be added to the procedure code billed with diagnosis code M1711. Modifier LT should be added to the procedure code billed with diagnosis code M1712.

Reason code 30940, provider not permitted to adjust

August 24, 2016, 11:43 pm

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A PROVIDER IS NOT PERMITTED TO ADJUST A PARTIALLY OR FULLY MEDICALLY DENIED CLAIM.

Q: We are receiving a return to provider (RTP) reason code 30940, so what steps can we take to avoid this reason code?

A: You will receive this reason code when you attempt to adjust a partially or fully medically denied claim. You are not permitted to adjust claims that are medically approved or denied.

Prior to correcting any claim, it is recommended that you review each line item service billed to determine if it has been medically denied or approved.

When the claim is within the timely filing limit, and there is medically denied line item(s) present:

• Cancel the original claim using type of bill (TOB) XX8
• If for a simple change, billing issue or to add/delete line items
• You are not permitted to cancel claims using direct data entry (DDE). You must cancel the claim though other electronic means or a hard copy (CMS-1450 form [UB-04]).
• Resubmit a corrected claim once the canceled claim has finalized (should take approximately two days)
• Add comments/remarks to the claim, must include all changes made
When the claim is beyond the timely filing limit, and a medically denied line item(s) present:
• Do not cancel and resubmit the claim
• Request a claim reopening using TOB XXQ
• If for a simple change, or billing issue
• You are not permitted to submit TOB XXQ using hard copy claims (CMS-1450 form [UB-04]). You must request the claim reopening via electronic media claims (EMC) or DDE.

If original claim does not include medically denied/reviewed lines, DDE users can F9 claim to reprocess.

If you do not agree with the decision for the medically denied line(s) and are within the time limit, you may submit a first level of appeal-redetermination.

ASC denial code N95, MA 109 AND M97

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Contractors shall deny services not included on the ASC facility payment files (ASCFS and ASC DRUG files) when billed by ASCs (specialty 49) using the following messages:

• Claim Adjustment Reason Code 8 - The procedure code is inconsistent with the provider type/specialty.

• RA Remark Code N95 - This provider type/provider specialty may not bill this service.

• MSN 26.4 - This service is not covered when performed by this provider.





If there is no approved ASC surgical procedure on the same date for the billing ASC in history, contractors shall return pass-through device claims/line items, brachytherapy claims/line items, drug code (including C9399) claims/line items, and any other ancillary service claims/line items such as radiology procedure claim/line items on the ASCFS list or ASCDRUG list as unprocessable using the following messages:

• Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate.

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.


• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).







Contractors shall deny the technical component for all ancillary services on the ASCFS list billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages:

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• Claim Adjustment Reason Code 171 - Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

• Remittance Advice Remark Code M97 – Not paid to practitioner when provided in this place of service. Payment included in the reimbursement issued the facility.

• Remittance Advice Remark Code M16 – Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).

ASC denial - N200, M97 AND M15

September 1, 2016, 11:25 pm

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Contractors shall deny globally billed ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages: 

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• N200 – The professional component must be billed separately

• Claim Adjustment Reason Code 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing. Note Refer to the 835 healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.






Contractors shall deny separately billed implantable devices using the following messages: 
• MSN 16.32 – Medicare does not pay separately for this service.

• RA Remark Code M97 - Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.


• RA Remark Code M15 - Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed;

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.

• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision.(contractor discretion)

If there is a related, approved surgical procedure for the billing ASC for the same date of service, also include the following message:

• MSN 16.8 - Payment is included in another service received on the same day.

Remark code N428, 5 and N425, CA96

September 6, 2016, 11:27 pm

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Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 

Contractors shall deny services for HCPCS with payment indicators C5 (Inpatient surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid under another fee schedule), U5 (Surgical unlisted service excluded from ASC payment. No payment made.), or X5 (Unsafe surgical procedure in ASC. No payment made. Use the following messages:

• MSN 16.2 - This service cannot be paid when provided in this location/facility.

• RA Remark N428 - Service/procedure not covered when performed in this place of service.

• Claim Adjustment Reason Code 5 - The procedure code/bill type is inconsistent with place of service.




Contractors shall deny services for CPT codes with payment indicators E5 (Surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.), or Y5 (Non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.) and use the following messages:

• MSN 16.10 – Medicare does not pay for this item or service.

• Claim Adjustment Reason Code 96 – Non-covered charges.

• RA Remark Code - N425 - Statutorily excluded services.


• RA Remark Code M16 - Alert: Please see our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

NOTE: Contractors shall assign beneficiary liability for facility charges HCPCS codes billed with ASC payment indicators C5, E5, U5 and X5.