Frequently Asked Questions Return to Provider (RTP) / Reason Codes

How do we find and print reports in FISS?

To access reports, go into FISS and choose R1 for Summary of Reports and press enter. This will allow you to view the 201 Daily, weekly, monthly and the 702 daily reports.

(October - December, 2009 FAQ - Reviewed June 2010)

My claim was in “T” status and someone at my facility suppressed it. Can I still work the claim?

Once the claim is suppressed it can no longer be worked and a new claim has to be submitted.

(July - September, 2009 FAQ - Reviewed June 2010)

I do not have access to DDE, so how can I find out if my claim is in RTP?

Providers without DDE access would need to contact the Provider Contact Center to find out if their claim has been RTP'd. The representative will advise if the claim is in RTP and if so, the provider will need to refer to their remit for additional information.

(April - June, 2009 FAQ - Reviewed June 2010)

My claim is being returned to provider with Reason Code 30960. What does this mean?

At times, you may need to adjust a claim after it has been paid or rejected to make changes (e.g., add or remove services). Claim adjustments can be made to paid or rejected claims (i.e.,

status/location P B9997 or R B9997). If a claim in a P status has been reviewed by Medical

Review and has one or more line items denied, adjustments can be made to the paid line items.

Please note: Adjustments cannot be made to any part of a denied line item on a partially paid claim.

(January - March, 2009 FAQ - Reviewed June 2010)

We are billing code J0885 and our claims rejecting, how can we prevent this rejection?

Effective January 1, 2008, all claims reporting ESAs J0881, J0882, J0885, or J0886 must report the most recent hemoglobin or hematocrit readings. For non-ESRD ESAs (HCPCS codes J0881 and J0885) reporting the modifier EA (anemia that is related chemotherapy), the hemoglobin or hematocrit are required to be below a certain level in order for the service to be medically necessary.

Contractors are instructed, per CR 5818, to deny ESA services that report HCPCS codes J0881 or J0885 with modifier EA when Hgb is > 10.0g/L or the Hct is > 30 percent. There is no exception to this requirement and there is no 4-week window at initiation where providers can report a level above 10.0 g/L or 30 percent and have the service paid. The entire discussion surrounding ESA administration for cancer conditions is outlined in the LCD and NCD 110.21.

(April - June 2008 FAQ -Reviewed December 2009 - Updated June 2010)

We have received claim rejects for reason code U5233 advising the patient elected a Medicare Advantage plan and the Medicare hospice benefit period was not elected. How can we verify the patient's eligibility?

When a beneficiary elects an MA plan, they no longer have coverage under the traditional Medicare Fee-For-Service program. As a result, FFS contractors, like Cahaba GBA, do not process the beneficiary's claim.

To reduce billing issues that may arise when the beneficiary has selected an MA plan:

Upon admission for Medicare-covered services, review all insurance cards a beneficiary may hold.
Verify the information on the card with the patient or their representative and determine if all the information is still valid.
Check the “PLAN INFORMATION” screen found on ELGA Page 1 and/or ELGH page 5 upon admission, and prior to submitting each billing transaction to Cahaba GBA.

(April - June 2008 FAQ - Reviewed December 2009 - Reviewed June 2010)

Our Medicare claims rejected as untimely. Do we have any recourse regarding this?

Information regarding timely filing requirements for Medicare claims can be found in the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, §70). Please review the information published in section 70.7 of this resource to determine the situations when exemptions may be granted to timely filing constraints. The Patient Protection and Affordable Care Act of 2010 (PPACA) mandated that claims for services on or after January 1, 2010 must be filed within one calendar year after the date of service. Claims for services from October 1, 2008 through December 31, 2009 must be filed by December 31, 2010.

(January - March 2008 FAQ - Updated March 2010 - Reviewed June 2010)

Do you publish information about claim submission errors (CSEs) and how to resolve them? If so, where can I find it?

The Cahaba Web page, Top Claim Submission Errors and How to Resolve is available for providers to review the top CSEs. Each reason code contains the reason for the error and provides an explanation and/or links to resources to assist in resolving/preventing the error in the future.

(July - September 2007 FAQ - Reviewed December 2009 - Reviewed June 2010)

Our claims are going to the RTP file for reason code 32103. Our claims contain an NPI. We don't understand why they won't process.

Reason code 32103 is received when the information found in the NPI crosswalk file does not match the information found in the FISS provider file. To resolve this reason code, verify the NPI entered on the claim matches the NPI that was assigned by the National Plan and Provider Enumeration System (NPPES). If the NPI was not entered correctly, correct the NPI and press “F9.”

Verify the legacy identifier number corresponds with the NPI on file with the NPPES. If the information on the NPPES is incorrect, providers should change their information with the NPPES.

https://nppes.cms.hhs.gov/NPPES/Welcome.do

(April - June 2007 FAQ - Reviewed December 2009 - Updated June 2010)

Why did my claim reject?

Claims can reject for a number of reasons. The most common reasons why claims reject are for eligibility errors, or duplicate claim submissions. Rejected claims can be identified with a status code of “R”. The reason code narrative assigned to a rejected claim will inform you as to the reason why your claim rejected.

(October-December 2005 FAQ- Reviewed December 2009 - Reviewed June 2010)

My claim rejected with reason code 38200. How do I keep this from occurring?

Reason code 38200 occurs when a provider submits multiple claims to Medicare for the same beneficiary with the same date of service. This reason code narrative states, "This claim is an exact duplicate of a previously submitted claim." You can avoid having claims reject due to the duplicate submission of billing transactions by following the tips found on the Top Claim Submission Errors for All Providers: Errors 38200 Web page.

(October-December 2005 FAQ - Reviewed December 2009 - Reviewed June 2010)

Why does my claim need correction?

Claims are returned to you for correction because the information contained on them is incomplete, incorrect or missing. These claims reside in the claims correction file, which is also known as the Return to Provider (RTP) file. Claims in your RTP file are found in FISS status/location T B9997. By viewing the reason code narrative in FISS, you can determine the reason why your claim needs correction. For more information about viewing reason codes and correcting claims, please review the information found in the Claims Correction section of the FISS Reference Guide. In addition, Cahaba also publishes a listing of the top reasons why claims need correction.

(October-December 2005 FAQ - Reviewed December 2009 - Reviewed June 2010)

I can't figure out how to fix my claim. The reason code doesn't make any sense.

Some reason code narratives are easy to interpret. Others are more difficult to decipher to know what exactly needs correction. The following tips may help when working with the more difficult reason codes:

If you are unsure what errors need correction after reading the reason code narrative, pick a few key words mentioned and then check the field locators or appropriate screens that correspond to verify the data listed is valid and doesn't conflict with what you billed.

Make a cheat sheet of the reason codes that are unclear or that a Cahaba customer service representative has assisted you with, and record notes in your own words that will help you resolve the same type of billing issue in the future.
If one reason code continually causes problems for you, mention the code to a customer service representative the next time you call Cahaba and obtain further clarification on the narrative and what causes this reason code to occur.

(October-December 2005 FAQ - Reviewed December 2009 - Reviewed June 2010)

How can I correct my claims using FISS?

To correct claims using FISS, providers will need to sign on to FISS and select the 03 (Claims Correction) option from the FISS Main Menu. The Claims Correction option that matches the provider type is keyed in. Once the Claim Summary Inquiry screen appears, providers can access their RTP file by entering their National Provider Identifier (NPI) and pressing <Enter>. Please note: the type of bill (TOB) defaults to a type of bill for your provider type. You may need to change this, depending on whether you submit different types of bills for your provider type. For example, skilled nursing facilities may need to check for 21, 22 or 23 types of bills.

Step-by-step instructions are available to assist providers in correcting their claims using the FISS system. They can be found in the Claims Correction section of the FISS Reference Guide.

(October-December 2005 FAQ - Reviewed March 2010 - Reviewed June 2010)

DDE is an excellent tool for editing claims that we have transmitted electronically. However, we can no longer edit MSP claims with the DDE service. We incur a monthly fee from our vendor to access DDE online yet we cannot use it to edit or repair DDE claims. What can we do?

As of October 5, 2009, CMS Change Request 6426 mandated that MSP claims cannot be submitted or adjusted through Direct Data Entry (DDE). Medicare providers are now required to submit MSP claims and adjustments electronically using the American National Institute (ANSI) ASC X12N 837 format, unless you meet the small provider exception to submit hardcopy claims. MSP claims submitted via DDE will be returned to provider with reason code 31265. If your vendor's software does not allow you to send or adjust MSP claims, you can use the free Microsoft Windows based claims submission software PC-Ace Pro 32. This software has the capability of sending MSP claims and adjustments electronically in the 837 format. Please refer to the EDI software downloads section on Cahaba's website. http://www.cahabagba.com/part_b/edi/free_claim_submission_software.htm

PC-Ace Pro 32 is free from Cahaba if you use your dial up service. If you choose to go through a vendor, you may incur a cost. Also, you can continue to utilize DDE to submit and adjust your non-MSP claims.

(January- March, 2010 FAQ - Reviewed June 2010)

Page last updated: July 29, 2010