Ordering/Referring Provider Denial Job Aid
If you have received a claim rejection/denial due to a missing/incomplete/invalid ordering provider name and/or NPI, you must correct and resubmit your claim in order for payment to be considered. Use the following chart for guidance on correcting your claim.
ANSI Reason Code | ANSI Remark Code | ANSI Definition | What to Do |
---|---|---|---|
16 | N265 N276 MA13 |
Claim/service lacks information which is needed for adjudication. Missing/incomplete/invalid ordering provider primary identifier. Missing/incomplete/invalid other payer referring provider identifier. Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code. |
The ordering/referring provider NPI was either missing from the claim, is not found on the ordering/referring physician file, or has been terminated. Step 1: Obtain the correct NPI for the ordering/referring provider information. Be sure to enter the name and NPI exactly as it appears in the PECOS records. Step 2: What suppliers can do to check the status of a claim denial for ordering/referring physician edits:
Step 3: Once you have obtained the correct name and NPI, submit a new initial claim. Be sure to enter the name and NPI exactly as it appears in the PECOS records. NOTE: Telephone Reopenings: CGS will not be correcting ordering/referring claim denials. Redeterminations: If you wish to appeal your claim, you must send the corrected information, and the Redeterminations department has up to 60 days to complete the request. So again, it is in your best interest to simply correct and submit a new initial claim. |
16 | N264 N575 MA13 |
Claim/service lacks information which is needed for adjudication. Missing/incomplete/invalid ordering provider name. Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records. Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code. |
The ordering/referring provider's name does not match the NPI. Step 1: Verify the ordering/referring provider name and NPI are correct using myCGS, the Jurisdiction C IVR, or the NPI Registry Step 2: What suppliers can do to check the status of a claim denial for ordering/referring physician edits:
Step 3: Once you have obtained the correct name and NPI, resubmit a new initial claim. Be sure to enter the name and NPI exactly as it appears in the PECOS records. NOTE: Telephone Reopenings: CGS will not be correcting ordering/referring claim denials. Redeterminations: If you wish to appeal your claim, you must send the corrected information, and the Redeterminations department has up to 60 days to complete the request. So again, it is in your best interest to simply correct and submit a new initial claim. |