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October 2008 Common Denials for CMS-1500 Claims Presented by EDS Provider Field Consultants Insert photo here.

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Presentation on theme: "October 2008 Common Denials for CMS-1500 Claims Presented by EDS Provider Field Consultants Insert photo here."— Presentation transcript:

1 October 2008 Common Denials for CMS-1500 Claims Presented by EDS Provider Field Consultants Insert photo here

2 2October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Agenda Session Objectives Edits and Audits Defined Edit and Audit Groups Types of Edits Types of Audits Top 10 Denials by Provider Type Top 25 Denials - Overview Helpful Tools Questions

3 3October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Session Objectives Understand the different edit groupings Learn the purposes of edits and audits Develop knowledge on how to correct the claim once the claim has denied Understand how to submit correct claims to avoid edit denials Learn how to quickly research and correct denied claims –Reduce aged accounts –Improve cash flow Answer your questions Provide avenues of resolution

4 4October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Edits and Audits Edits - are designed to verify data submitted on the claim form and ensure claims are submitted with the necessary data to process the claim Audits - are designed to compare the claim being processed to the claims that have already been paid (paid history) Edits and audits are designed to ensure claims are paid within policies set forth by the Office of Medicaid Policy and Planning (OMPP) and Centers for Medicare & Medicaid Services (CMS)

5 5October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Edit and Audit Groups Validation Edits Relational Edits Provider Edits Recipient Edits Prior Authorization (PA) Edits Reference Edits History Audits Medical Policy Surveillance and Utilization Review (SUR) Edits Pharmacy Miscellaneous (informational) Edits

6 6October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Types of Edits Validation Edits (EOB 0100 to 0499) - used to validate the presence and format of data entered on the claim  Most Common: 0202 – Billing Provider I.D. in Invalid Format Relational Edits (EOB 0500 to 0899 and 8000 to 8999) - used to compare or relate multiple fields on the current claim  Most Common: 0558 – Coinsurance/Deductible Amount Missing Provider Edits (EOB 1000 to 1999) - are performed on the provider identification numbers such as billing, rendering, and referring Legacy Provider Identifier (LPI) and National Provider Identifier (NPI)  Most Common: 1004 – Rendering Provider Not Eligible to Render Service on DOS

7 7October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Types of Edits Recipient Edits (EOB 2000 to 2999) - are performed on the member identification number (RID) to ascertain member eligibility  Most Common: 2017 – Recipient Ineligible on DOS Due to Enrollment in a Managed Care Organization Prior Authorization Edits (EOB 3000 to 3999) - are performed to ascertain that billed services which require prior authorization are prior authorized  Most Common: 3001 – DOS Not on PA Master File Reference Edits (EOB 4000 to 4999) - check various reference tables used in claims processing, such as formulary file, procedure code table, modifier table and pricing table  Most Common: 4021 – Procedure Code Vs. Program Indicator

8 8October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS More Audits SURS Edits (EOB ) - were established to allow Surveillance and Utilization Review (SUR) examiners to perform prepayment administrative reviews on identified providers and recipients  Most Common: 7002 – Claim Denied for DUR Reasons

9 9October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Types of Audits History Related Audits (EOB 5000 to 5999) - compare the current claim with paid claims in history to determine if a claim is a duplicate of a previously paid claim  Most Common: 5001 – Exact Duplicate Medical Policy Audits (EOB 6000 to 6999) - track and restrict certain services based on eligibility and coverage policy set forth by the OMPP and CMS  Most Common: 6000 – Manual Pricing Required

10 October 2008 Top 25 Denials – CMS-1500 Claims

11 11October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS The rendering physician LPI number is not in a valid format on the CMS-1500 or dental claim The rendering LPI, if still submitted on the claim, must be nine numeric characters Resubmit the claim with rendering NPI only, or NPI and valid rendering LPI Rendering Physician Number Not in Valid Format (1) Edit 0232

12 12October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (2) Edit 5001 Claim being processed is an exact duplicate of a claim on the history file or another claim being processed in the same cycle Research prior claims billed for “paid” status Exact Duplicate

13 13October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (3) Edit 2017 The recipient was not eligible for the fee-for- service medical assistance on the date of service because they were enrolled in the risk- based managed care program The service should be billed to the appropriate managed care organization Recipient Ineligible on Date of Service Due to Enrollment in a Managed Care Organization

14 14October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (4) Edit 0593 Denied detail lines must be re-billed separately on a separate claim form –Occur when Medicare denies a detail line –Are not crossover claims –Do not include the paid detail lines on the new claim –Processed as TPL claims –Include the Medicare Remittance Notice (MRN) with the claim Medicare Denied Detail

15 15October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (5) Edit 0558 CMS Field 22 Left = The sum amount for Medicare Coinsurance, Deductible and Psych Reduction Right = Medicare Paid Amount Coinsurance and Deductible Amount Missing

16 16October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Include member identification on the claim attachment Clearly state the reason for non-coverage on the TPL attachment Ensure that the primary insurance company name on the attachment matches the information in the member’s file Hand write “Medicare replacement policy” on the EOB, if applicable TPL listed is no longer valid Recipient Covered by Private Insurance (with Attachment) (6) Edit 2505

17 17October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (7) Edit 4021 Procedure code billed is restricted to a specific program –Package B –Package C –590 Verify eligibility prior to rendering service Submit claim with appropriate procedure code Procedure Code vs. Program Indicator

18 18October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Claims will deny if the quantity dispensed is missing Include quantity dispensed and unit of measure (EA, GM, ML) (8) Edit 0219 Quantity Dispensed Is Missing

19 19October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Claims requiring a National Drug Code (NDC) must have a unit qualifier (unit of measure) CMS-1500 – Field 24 a-h (shaded section) –See Bulletin BT (9) Edit 0810 NDC Unit Qualifier (Unit of Measure)

20 20October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Billing provider number is not enrolled in the program on the date of service –Verify the correct LPI was reported on the claim To initiate a new enrollment –Download the Provider Enrollment Application via –Complete the form and submit to Provider Enrollment (10) Edit 1003 Billing Provider Not Enrolled at Service Location for Date of Service

21 21October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS All claims requiring NDC information must have NDC present on claim CMS-1500 – Field 24 a-h (shaded section) –See Bulletin BT (11) Edit 0217 NDC Missing

22 22October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS If a physician or outpatient claim is submitted for a Medicare Part B covered service and recipient is covered by Medicare Part B Claim will deny if no attachment indicating Part B has been billed Bill Medicare Part B first (12) Edit 2502 Recipient Covered by Medicare Part B (No Attachment)

23 23October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (13) Edit 0268 If the billed amount is missing for any detail line, the claim will deny Verify each detail line has a billed amount Billed Amount Missing

24 24October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (14) Edit 2003 The recipient was not eligible on the date of service Always verify eligibility on the date the member is seen Recipient Ineligible on Date of Service

25 25October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS CMS-1500 –Field Locator 17b (NPI) –Primary medical provider NPI and/or LPI is missing/invalid on the claim form (15) Edit 1044 Care Select Member’s PMP Is Missing

26 26October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Rendering provider number is not enrolled in the specific program (for example, 590 Program) on the date of service –Verify the rendering provider’s enrollment via Web interChange –If necessary, complete the Provider Update Form to enroll the provider in the program (16) Edit 1004 Rendering Provider Not Eligible to Render Service on this Program for the Date of Service

27 27October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS The billing LPI and NPI are submitted on the claim. The billing NPI does not crosswalk to an LPI in the provider database Verify NPI is linked to the correct LPI Verify claim was billed with correct NPI/LPI combination (17) Edit 1108 Billing NPI Has No Matching LPI

28 28October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS The rendering provider is not the Care Select member’s primary medical provider (PMP) and there is no certification code on the claim CCF will be generated Resubmit claim with the referring PMP’s two- digit certification code in block 19 of CMS-1500 (18) Edit 1042 Certification Code is Missing - Care Select

29 29October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Applicable to medical claims reporting processing and pricing modifiers Verify procedure/modifier combination is reported correctly –IHCP Fee Schedule –IHCP Provider Manual (19) Edit 4209 No Pricing Segment for Procedure/Modifier Combination

30 30October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Examples of claims that will generate a CCF: –Claims over one year old (0512) –Certification code missing (Care Select) –Claims that require attachments Sterilization consent form Periodontal Chart CCF will not print for: –Electronic claims with attachments (Region 21) Note: Electronic claims will remain in a CCF status for 45 days, or until the attachment is received CCF Not Returned within 45 Days (20) Edit 0499

31 31October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS The rendering provider in block 24j is not on the provider database Verify the accuracy of the rendering provider number (21) Edit 1007 Rendering Provider Not on Provider Database

32 32October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (22) Edit 1049 Provider specialty or procedure code on the claim requires a referral from the PMP The rendering provider is not the member’s PMP Claim must have the referring PMP provider number in block 17a (LPI) or 17b (NPI) Claim must have referring PMP certification code in block 19 Care Select Member’s PMP Is Missing

33 33October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (23) Edit 0513 The recipient name and RID number on the claim must match the recipient database Always verify eligibility on the date of service Verify recipient name and RID number Recipient Name and Number Disagree

34 34October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS (24) Edit 3001 Applies when the code billed requires Prior Authorization (PA) for that program, and the date(s) of service indicated on the claim do not fall within the start/stop dates prior authorized for that code Verify PA was approved via Web interChange or Automated Voice Response (AVR) at (317) in the Indianapolis local area or toll-free Contact HCE Prior Authorization Department at (317) or toll-free at Date(s) of Service Not on PA Database

35 35October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS The claim was submitted with rendering NPI only, and the NPI is not reported to any LPI Report the rendering NPI Rendering NPI Info Submitted Not Reported to an LPI (25) Edit 1120

36 36October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS IHCP Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance – , or –(317) in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant –View a current territory map and contact information online at Avenues of Resolution Helpful Tools

37 37October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS Questions

38 38October 2008 COMMON DENIALS FOR CMS-1500 CLAIMS EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2008 Electronic Data Systems Corporation. All rights reserved. EDS 950 N. Meridian St., Suite 1150 Indianapolis, IN Presentation by EDS Provider Field Consultants


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