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Top Claim Submission Errors

Claim Submission Errors (CSEs) cause your billing transactions to either reject or move to your Return to Provider (RTP) file for correction and create unnecessary costs to the Medicare program. Remember that it is your responsibility as a Medicare provider to ensure the information submitted on your billing transaction is correct and compliant with Medicare regulations. 

Providers should be aware what action may be taken when they demonstrate a pattern of submitting claims inappropriately, incorrectly or erroneously, including a referral to the Office of Inspector General (OIG) for Medicare fraud or abuse. 

Below is a list of the most recent top 10 errors.Scoll down the page to access the specific error/reason code, as well as resources you can use to avoid future billing errors.

Quarter, YearErrorClaim CountClaim Processing Result
Claims Issue DetailsQ3, 2016

38200

30288Reject
Claims Issue DetailsQ3, 2016

39934

26032Reject
Claims Issue DetailsQ3, 2016

38031

10410Reject
Claims Issue DetailsQ3, 2016

C7010

10381Reject
Claims Issue DetailsQ3, 2016

39929

8185Reject
Claims Issue DetailsQ3, 2016

U5200

5329Reject
Claims Issue DetailsQ3, 2016

38032

5171Reject
Claims Issue DetailsQ3, 2016

38038

5043Reject
Claims Issue DetailsQ3, 2016

34538

4873Reject
Claims Issue DetailsQ3, 2016

34540

2393Reject

First Quarter 2013 (January, February & March)   

 

1.  Error C7010 

Reason for Error: An inpatient, outpatient or SNF claim has service dates equal to or overlapping a hospice election period. Therefore, no Medicare payment can be made.  

Claim Processing Result: Reject 

How to Prevent/Resolve:

  • Verify with the beneficiary or their representative what health care services they are currently receiving at the time the service occurs.
  • Providers can also utilize the Interactive Voice Response System (IVR) to access beneficiary eligibility information. The IVR instructions are located on the Cahaba GBA website under the Contact Us section.
  • Review ELGA page 2 at the time of admission and prior to submitting claims to Medicare to determine whether the beneficiary has elected the hospice benefit and whether this election impacts your dates of service.
  • If services are unrelated to the terminal diagnosis, ensure condition code “07” is entered in FL 18-28 of the CMS-1450 claim form or enter in the first available COND CODES field on FISS page 01.

Condition code “07” can only be used when the services are unrelated to the terminal diagnosis; any other use of condition code “07” may be considered abusive.


2.  Error 31577

Reason for Error: The total number of units for revenue codes 521, 522 and 91X exceed the number of days in the statement covers billing period. 

Claim Processing Result: Return to Provider 

How to Prevent/Resolve:  Providers should reduce the number of units to one. Charges for each visit are combined and entered on one revenue code line.  The usual unit billed for RHCs is “1” except in rare circumstances. Also check for possible invalid revenue codes other than 521 and 522 on the line.  


3.     Error U5233

Reason for Error: Service within HMO period and no hospice involvement or services not within hospice period.   

Claim Processing Result: Reject 

How to Prevent/Resolve:

  • Upon admission for Medicare-covered services, review all insurance (including Medicare Part D) cards the beneficiary has and verify the information on the card is valid.
  • Providers can also utilize the Interactive Voice Response System (IVR) to access beneficiary eligibility information. The IVR instructions are located on the Cahaba GBA website under the Contact Us section.
  • Upon admission and prior to billing Cahaba, verify whether a Medicare Advantage (MA) plan will impact the dates of service by checking the “PLAN INFORMATION” screen found on ELGA Page 1. See the Checking Beneficiary Eligibility section of the FISS Reference Guide for more information on using these screens.
  • Since MA plan election records are updated the first part of each month, providers whose dates of service span two consecutive months or extend beyond 30 calendar days are encouraged to check ELGA monthly.
  • If the OPT code is a ‘C’, the MA plan is responsible for processing the claim.
  • If the OPT code is a ‘1’, services may be submitted to Cahaba for processing.
  • § According to the Medicare Claims Processing Manual (CMS Pub. 100-04, Ch. 11, §40.2.2), Medicare fee-for-service (FFS) contractors maintain payment responsibility for managed care enrollees who elect hospice.
  • Review the OPT field on the ELGA page 1 to determine where the claim needs to be sent for payment.
  • If the MA plan election is posted to ELGA in error, the MA plan will need to correct this information. Providers should contact the MA plan directly to update the beneficiary’s record.
  • If the MA plan election was correctly posted to the beneficiary’s file and impacts your dates of service, you must look to the MA plan for reimbursement. Do not submit a claim to Cahaba unless the eligibility file also indicates the FFS contractor is responsible for processing the Beneficiary’s claims.
  • Access the MA Claims Processing Contacts directory, which contains a list of all active Medicare contracts and their corresponding plan type.

Additional resources:   Beneficiary Eligibility Information FAQs 


4.     Error 32402 

Reason for Error:  According to the revenue code table (Option 13 on the inquiry

Menu on FISS), a HCPCS is required for the line item being edited. The revenue code has either been billed without a HCPCS code (when required) or is not valid for the HCPCS being billed.

Claim Processing Result:  Return to Provider

How to Prevent/Resolve:    

  • Check the HCPCS inquiry screen (Option 14 on the Inquiry Menu on FISS) to determine allowable revenue codes for the HCPCS being billed.
  • Verify the HCPCS code(s) billed.
  • Verify the revenue code (s) billed.

Online users make corrections and press F9 to update the claim.  All other providers make corrections to the claim and return to Medicare Contractor.


5.     Error C7252

Reason for Error:  The outpatient claim was submitted with a non-therapy service and the detail line item date of service is not present.

Claim Processing Result: Reject

How to Prevent/Resolve:

If the detail line date of service is not present, use the “from and thru” date. When the “from” and “thru” dates are used, the dates may overlap or be within the posted SNF inpatient Part A claim (21x) in history.


6.     Error U5200 

Reason for Error: The health care financing administration’s records indicate that the beneficiary is not entitled to Medicare coverage for the type of services billed on the claim.  

Claim Processing Result: Reject 

How to Prevent/Resolve:

  • Verify and validate the beneficiary Medicare Part A and Part B enrollment on ELGA page 01 prior to each admission and billing. For more information on how to read these screens, please access the Checking Beneficiary Eligibility section of the FISS Reference Guide.
  • Providers can also utilize the Interactive Voice Response System (IVR) to access beneficiary eligibility information. The IVR instructions are located on the Cahaba GBA website under the Contact Us section.
  • Keep a current copy of the beneficiary’s red, white and blue Medicare card in the beneficiary’s file

Additional Resource: Beneficiary Eligibility Information FAQs


7.     Error 12206

Reason for Error: Sum of covered days and non-covered days must equal the statement covers period.

Claim Processing Result: Return to Provider

How to Prevent/Resolve:

  • Verify covered and non-covered days.
  • Verify statement from and through dates.
  • Verify patient status. If 30 add one additional day to include the through date.

Enter correct data and update the claim.


8.     Error U5210

Reason for Error: The beneficiary’s entitlement for Medicare coverage was terminated prior to the first date for services provided on the claim.  Therefore, no Medicare payment can be made. 

Claim Processing Result: Reject

How to Prevent/Resolve:

  • Verify and validate the beneficiary Medicare Part A and Part B enrollment on ELGA page 01 prior to each admission and billing. For more information on how to read these screens, please access the Checking Beneficiary Eligibility section of the FISS Reference Guide.
  • Providers can also utilize the Interactive Voice Response System (IVR) to access beneficiary eligibility information. The IVR instructions are located on the Cahaba GBA website under the Contact Us section.
  • Keep a current copy of the beneficiary’s red, white and blue Medicare card in the beneficiary’s file

Additional Resource: Beneficiary Eligibility FAQs


9.     Error 30905

Reason for Error: The incoming adjustment cannot find an original claim to match.

Claim Processing Result: Return to Provider

How to Prevent/Resolve:

Verify that the following fields on the adjustment are identical to those same fields on the remittance advice containing the original payment:

  • Health Insurance Claim (HIC) number
  • X-Reference Document Claim Number (DCN)
  • First two positions of the type of bill (TOB)
  • Dates of service and provider number

Please verify billing and if appropriate correct and resubmit.


10.  Error U6802

Reason for Error: Medicare Secondary Payer (MSP) indicated on claim, no direct match on auxiliary record iteration, or dates match on claim, but no direct match on MSP type.

Claim Processing Result: Return to Provider

How to Prevent/Resolve:

  • Use the Admission Questions to Ask Medicare Beneficiaries to determine the correct primary payer
  • Verify beneficiary eligibility by checking ELGA prior to each admission and billing. For more information on how to read these screens, please access the Checking Beneficiary Eligibility section of the FISS Reference Guide.
  • Providers can also utilize the Interactive Voice Response System (IVR) to access beneficiary eligibility information.
  • Please correct and resubmit the claim.

Page last updated:  June 3, 2013

 

 

 

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