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 |
---|---|---|---|
183 | N574 | The referring provider is not eligible to refer the service billed. Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer. Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. OR Your supplier number is not eligible to provide this item. |
The ordering/referring physician listed on the claim is not eligible to prescribe Power Mobility Devices (PMDs) based on his/her physician specialty, as listed in PECOS. Step 1: If you submitted the ordering/referring physician information incorrectly, correct the information, and resubmit a new claim. REFERENCE: MLN Matters Article MM8239. NOTE: CGS will not correct ordering/referring claim denials via telephone reopenings. If you wish to appeal your claim, you must submit a redetermination with the corrected information, and the Redeterminations department has up to 60 days to complete the request. While submitting a redetermination is an option, CGS recommends that you simply correct and submit a new initial claim. OR Your supplier number is not eligible to provide this item. Step 1: If the licensure information on file is incorrect, submit a “Change of Information” on the Medicare enrollment application (CMS-855S) form to the National Provider Enrollment (NPE) along with any applicable licenses and/or certifications. Step 2: Once your licensure information has been updated with the NPE, resubmit a new initial claim NOTE: Redeterminations: If you disagree with the claim decision, submit a redetermination request. NOTE: CGS will not correct ordering/referring claim denials via telephone reopenings. If you disagree with the claim decision, submit a redetermination. |
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: Use the DME myCGS web portal 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: CGS will not correct ordering/referring claim denials via telephone reopenings. If you wish to appeal your claim, you must submit a redetermination with the corrected information, and the Redeterminations department has up to 60 days to complete the request. While submitting a redetermination is an option, CGS recommends that you 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: CGS will not correct ordering/referring claim denials via telephone reopenings. If you wish to appeal your claim, you must submit a redetermination with the corrected information, and the Redeterminations department has up to 60 days to complete the request. While submitting a redetermination is an option, CGS recommends that you simply correct and submit a new initial claim. |