Frequently Asked Questions about Checking Status of Claims

Why is it taking Cahaba more than 14 days to process my Medicare claims?

The earliest Medicare intermediaries are able to pay “clean claims” (those needing no intermediary intervention or investigation, or correction by the provider) submitted electronically is 14 days after the received date of the claim.  Per the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, Globe to indicate www link. § 80.2.1.1), intermediaries, like Cahaba, have 30 days to process clean claims.  While the typical timeframe to process claims is less than this, intermediaries have the full 30 days from the receipt date of a clean claim to process it.  For this reason, providers should not expect that every clean claim submitted to their Medicare intermediary will be paid on the 14th day after it is received. Claims not processed within the 30-day timeframe may be paid with interest.

Home health providers should be aware that Requests for Anticipated Payment (RAPs) are not considered home health claims.  Therefore, there is no specified timeframe for when RAPs must be processed by intermediaries, nor are RAPs subject to claims processing timeliness standards.  In addition, RAPs are not eligible for interest payments when a processing delay occurs (Pub. 100-04, Ch 10, Globe to indicate www link. § 10.1.12). 

(April – June 2008 FAQ  – reviewed Nov. 2008)

 

My claim is still processing, but has reason code F5052 assigned to it.  What causes this?

The Fiscal Intermediary Standard System (FISS) assigns reason code F5052 to claims when the Common Working File (CWF) is unable to locate the beneficiary’s Health Insurance Claim Number (HICN) as it was submitted on the Medicare billing transaction. The most common reasons why providers receive this reason code include:

  • the HICN has not been previously processed by this office and the system is attempting to locate it at another CWF host site;
  • the HICN is in the process of being updated or changed; OR
  • the HICN submitted on the claim is not valid.

If your claim is suspended (FISS S/LOC S BXXXX or S MXXXX) while the system is attempting to access the HICN at another CWF host site, please be aware that this process takes time. Once the beneficiary’s HICN has been located at the host site, a “link” is created and the system will be able to process future claims you submit for this beneficiary more quickly.  Additional information on suspended claims can be accessed at the Claims in a Suspended Status/Location (S/LOC) Web page.

To avoid billing errors for invalid or changed HICNs, providers are encouraged to authenticate the beneficiary’s HICN by reviewing the “CN” and “CORRECT CN” fields found on page 1 of ELGA or ELGH, prior to submitting billing transactions to Medicare. Information about accessing and reading these screens can be found in the Checking Beneficiary Eligibility section of the FISS Reference Guide or the Cahaba online course, Verifying Beneficiary Eligibility.

If your claim is rejected (FISS S/LOC R B9997) for an incorrect HICN, you will need to submit the corrected HICN on a new claim. If your claim is in the Return to Provider (RTP) S/LOC T B9997, you can correct the HICN by entering the correct HICN in the “PROCESS NEW HIC” field on FISS Claim Page 01.  Detailed instructions for using this field can be found in the Claims Correction Menu section of the FISS Reference Guide.

(April – June 2008 FAQ  – reviewed Nov. 2008)

 

I have claims in FISS status/location S B90F0, as well as other suspended status/locations.  What can I do to get these claims to process?

Claims in this status/location are suspended while they are comparing the information submitted on them to the beneficiary’s information posted to the Common Working File (CWF) and can remain suspended for 6 to 7 business days.  No provider intervention is required for claims in this status/location.

A listing of common suspended status/location codes can be found on the Cahaba Claims in a Suspended Status/Location (S/LOC) Web page.

(April – June 2008 FAQ  – reviewed Nov. 2008)

 

What’s the difference between a claim in RTP, a claim that rejected and a denied claim?

Claim Processing Result

FISS Status/ Location

Reason(s) for Result

Provider Action Taken

Return to Provider (RTP) claim

T B9997

Claim has missing, invalid or incorrect information detected by Fiscal Intermediary Standard System (FISS) or Common Working File (CWF) edits.
  1. Correct claim using “Claims Correction” option in FISS OR
  2. Submit new claim with correct information

Rejected claim

R B9997
  1. Beneficiary eligibility issues (i.e. overlapping hospice election)
  2. Duplicate billing transaction received.
  1. Submit adjustment when appropriate (See  Claim Correction section of the FISS Reference Guide) OR
  2. Resubmit claim after resolving reason for claim rejection OR
  3. No action required for duplicate claims.

Fully denied claim*

D B9997*
  1. Claim selected for Medical Review and no services determined to be payable by Medicare.
  2. Claim selected for Medical Review and documentation was not received timely.
  1. If disputing denied charges, submit appeal within 120 days of denial date.

 

*Note:  Partially denied claims are found in FISS status/location P B9997. If you are disputing a denied charge, see the “Provider Action Taken” information above for FISS Status/Location D B9997. Adjustments can be made to the paid (covered) lines of partially denied claims. 

(July – Sept. 2007 FAQ  – reviewed Nov. 2008)

 

Is there any way we can verify whether our Medicare claims paid correctly other than calling Cahaba for a payment explanation?

For providers who are paid under a Prospective Payment System (PPS), such as home health agencies the Centers for Medicare & Medicaid Services (CMS) has a Web page available, which contains PPS pricing information.  By downloading the free versions of the Pricer for their provider type, providers can predict payment for services they plan to provide, calculate the payment they will receive for an individual claim or validate they have received the correct payment for an individual claim. In addition, there are rates and fee schedules available on the Cahaba Web site.  

(April - June 2007 FAQ  – updated Nov. 2008)

 

I’m having problems understanding the information printed on the remittance advice (RA).  Where can I find more information on how to read it?

The Centers for Medicare & Medicaid Services (CMS) has educational products available free of charge to providers to assist them in understanding the Medicare remittance advice.  These include a detailed reference manual, “Understanding the Remittance Advice:  A Guide for Medicare Providers, Suppliers, Physicians and Billers”, and a web-based training course, “Understanding the Remittance Advice for Institutional Providers”.  The latter is also available via CD-ROM.  Providers can download or order these resource materials through the CMS MLN Products Catalog Globe to indicate www link. or the MLN Product Ordering Page.  Globe to indicate www link.  

(Jan. – March 2007 FAQ  – reviewed Nov. 2008)

 

What does it mean if my claim is in an “S” status code?

An “S” status code indicates that your claim is in a suspended status/location (S/LOC).  Generally, providers do not need to take action for claims that are suspended, as all claims temporarily suspend in different S/LOC as they process through the Fiscal Intermediary Standard System (FISS). 

(Oct. - Dec. 2006 FAQ  – reviewed Nov. 2008)

 

Is provider action ever needed for suspended claims?

The only time provider action is needed for claims in a suspended S/LOC is when the claim encounters a medical review edit, which causes an Additional Development Request (ADR) to be generated. FISS S/LOC "S B6001" identifies claims that generate an ADR. Providers are encouraged to return their documentation to the Cahaba Medical Review Department within 30 days of the claim moving into the S B6001 S/LOC. If the documentation is not received timely, FISS automatically denies the claim on the 46th day after the ADR request was generated.

At times, suspended claims may require manual intervention by Cahaba staff to successfully process in FISS. These claims are monitored, and worked in the order they are received. These claims can be identified with an "S" status code, followed by a location code beginning with "M", indicating "manual" intervention. With the exception of claims in ADR (S M50MR and S M51MC), providers are encouraged to call Cahaba when their claims have been in an "S M0XXX" S/LOC for longer than 30 days.

(Oct. - Dec. 2006 FAQ  – reviewed Nov. 2008)

 

How can I tell if Cahaba received my claims?

Providers with electronic access to FISS don't need to call Cahaba's Provider Contact Center (PCC) to determine the receipt of billing transactions. To identify if your claims were received or where your claims are in the Fiscal Intermediary Standard System (FISS):

  1. Log on to FISS
  2. Enter "01" and press <Enter>
  3. Enter "12" and press <Enter>
  4. MAP 1741 will appear

FISS Screen Representation

  1. Enter your National Provider Identifier in the NPI field and patient's Medicare number in the HIC field
  2. Enter the "FROM" and/or "TO" dates of the claim and press <Enter>
  3. FISS will retrieve a listing of transactions for claims submitted with your provider identifier for the HIC number and dates of service entered

FISS Screen Representation

(Jan.-March 2005 FAQ  – updated Nov. 2008)

 

How can I tell if my claims reject?

To use FISS to determine whether your claim has rejected, you can use FISS Inquiry Option 12.  Instructions for using this inquiry option are found in the Inquiry Menu section of the FISS Reference Guide.  Claims that reject are found in FISS status/location, R B9997. You will need to enter this status/location in the S/LOC field when using Inquiry Option 12. 

(Jan.-March 2005 FAQ  – reviewed Nov. 2008)  

 

How can I tell if I will receive payment for my claims?

You can use FISS Inquiry Option 12 or FISS Inquiry Option 56 to check if you have claims for which payment will be issued.  Instructions for using these inquiry options are found in the Inquiry Menu section of the FISS Reference Guide.

When claims have been approved for payment, they can be found in FISS status/location, P B9996. 

(Jan.-March 2005 FAQ  – updated Nov. 2008)

 

How can I tell if I have an Additional Development Request (ADR)?

At times, the status and location codes applied to your claims by FISS identify that you need to take action.  Such is the case when a claim has been selected for Medical Review and an ADR is issued.

You can use FISS Inquiry Option 12 or FISS Inquiry Option 56 to check if you have claims for which an ADR has been issued.  Instructions for using these inquiry options are found in the Inquiry Menu.

Providers should become familiar with the following FISS status/location codes, which are specific to the ADR process.:

  • S B6001 (indicates an Additional Development Request (ADR) was initiated)
  • S M50MR or S M51MC (indicates provider-submitted ADR information was received by the Medical Review department in the Cahaba office in Des Moines, Iowa)

(Jan.-March 2005 FAQ  – updated Nov. 2008)

Where is my claim in FISS?

FISS applies a Status Code to your billing transactions to help you identify where they are in the processing phase. An alpha character always identifies a status code. In addition to a status code, a Location Code is also applied to your billing transactions. Familiarity with these codes will inform you what is happening to your billing transactions.

For more information regarding how to use FISS to check claim status, access the Inquiry Menu.

(Jan.-March 2005 FAQ  – updated Nov. 2008)

 

I don't see a claim on my Remittance Advice.  How can I check its status?

To identify where your claims are in the Fiscal Intermediary Standard System (FISS), use Inquiry Option 12.  Instructions for using this inquiry option are found in the Inquiry Menu.

(Jan.-March 2005 FAQ  – updated Nov. 2008)

 

I'm unfamiliar with a status location. Does this mean there a problem with my claim in this status/location?

A listing of common FISS status/location codes can be accessed in the FISS Overview section of the FISS Reference Guide. This section also contains a table, which details how locations are determined in FISS.  

(Jan.-March 2005 FAQ  – updated Nov. 2008)

Page last updated: December 4, 2008

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