LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
  5. CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

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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 RegistryExternal Website.

Step 2: What suppliers can do to check the status of a claim denial for ordering/referring physician edits:

  • Use myCGS online web portal. myCGS will provide you with an explanation of the denial.

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.

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