Georgia
Top Five Reasons for Claim Rejections for November 2006

Audit trails show which of your claims were accepted by the Cahaba GBA Part B processing system, along with claims that were rejected and the reason for the rejection. Referring to this report will allow you to correct and resubmit claims quickly, resulting in a dramatically reduced turnaround time. You will also become aware of any major problems with your claims so they can be corrected before they create an interruption in your cash flow. Audit trail reports are available the next business day for files that are received before 4:30 p.m. Eastern Time. If you are not receiving your audit trails contact your software vendor, billing service, or clearing house.

In order to increase the number of claims that successfully pass through audit trails and into processing Cahaba GBA Part B EDI Services is providing you with the top five reasons for claim rejections. For the month of November 2006, these are:

1. 209- INVALID LAST NAME FOR HIC NUMBER -16,696 claims

The last name submitted for the beneficiary does not match the last name we have on record for the HIC number on the claim.

2. 210- INVALID FIRST NAME/INIT FOR HIC - 15,764 claims

The first name submitted for the beneficiary does not match the first name we have on record for the HIC number on the claim.

3. 434- PROC CODE REQUIRES REFERRING UPIN - 10,680 claims

There is a procedure code on the claim that requires a Unique Physician's Identification Number (UPIN). This is required for diagnostic procedures such as x-rays, lab work, EKGs, etc. The UPIN of the physician who ordered the test should be used. A UPIN begins with a letter and is followed by five digits (eg. Z12345).

4. 421- DIAG CODE (XXXXX) INVALID FOR DATE SVC - 9,186 claims

The invalid diagnosis code will appear inside the parenthesis. Be sure that you are using the latest ICD-9 diagnosis codes, and that the code you are using is the most specific one. Also be sure that you are not using a date of service that is before the effective date of the diagnosis code.

5. 380- OTAF AMOUNT REQUIRED WITH CAS/CO (CONTRACTUAL OBLI –5,215 claims

The claim was a Medicare Secondary Payer (MSP) claim with a group code ‘CO’ given for an adjustment from the primary payer. This indicates the provider has a contract with the primary payer to accept the primary payer’s approved amount as payment in full (OTAF). The OTAF amount must be submitted on the claim in this circumstance and was missing.

For an explanation of how to submit MSP claims electronically, and for definitions of OTAF and other terms, please see these articles on our website:

https://www.cahabagba.com/part_b/msp/Providers_Electronic_Billing_Instructions.htm

https://www.cahabagba.com/part_b/whats_new/news_msp_billing_clarification.htm