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Ordering/Referring Provider Denial Job Aid

For dates of service on or after January 6, 2014, if the ordering/referring provider name and NPI on a DMEPOS claim do not have current enrollment information in PECOS, the claim will be rejected or denied. Based on a review of claim data, CGS anticipates a significant number of claim denials related to this edit.

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:

  • Use myCGS online web portal. myCGS will provide you with an explanation of the denial and will link you to the PECOS Dear Physician letterPDFRevised October, 2018

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 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 and will link you to the PECOS Dear Physician letterPDF Revised October,2018.

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.

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