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Reason Code Search and Resolution

Disclaimer: This is not a complete listing of reason codes. Other reason codes will be added.

This Reason Code Search and Resolution tool has been designed to aid Medicare providers in reviewing reason codes and how to resolve the edit or use them for determining if other action is needed. You may search this database by reason code or keyword. All records matching your search criteria will be returned for your review. If you are aware of a reason code not listed or a description and/or a resolution is not clear, please send your suggestion for reason code addition or update to J15_PARTA_Education@cgsadmin.com.

If you wish, you may also view the entire listing of reason codes, their descriptions, resolutions, and additional billing information by clicking on the "Show all Reason Codes" option.

Reason Code U5233

Description:

The services on the claim fall within or overlap a Medicare Advantage (MA) managed care plan enrollment period.

Resolution:

  • Obtain the managed care plan information from the Direct Data Entry (DDE) system, the Interactive Voice Response (IVR), or the myCGS web portal. Submit a claim to the managed care plan for payment.
  • For certain inpatient services, an informational-only claim must be submitted to Medicare for the purpose of tracking benefit utilization and, in some cases, for the provider to receive special payments. Informational-only claims are submitted as follows:

      Acute IRF LTCH CAH SNF/SB
    Non-teaching facility Covered claim with condition code 04 for Disproportionate Share Hospital (DSH) payment Covered claim with condition code 04 and the Case-Mix Group (CMG) code and assessment date from the IRF Patient Assessment Instrument (PAI) for Low-Income Patient (LIP) payment Covered claim with condition code 04 for DSH payment Covered claim with condition code 04 for Electronic Health Record (EHR) incentive payment Submit claim to the managed care plan for payment; submit the same claim to Medicare to track benefit utilization
    Teaching facility Covered claim with condition codes 04 and 69 for DSH and Direct Graduate Medical Education (DGME) payments Non-covered claim with condition codes 04 and 69 for LIP and DGME payments Non-covered claim with condition codes 04 and 69 for DSH and DGME payments Not applicable Not applicable

    Note: Managed care informational-only claims are not required for outpatient hospital or Inpatient Psychiatric Facility (IPF) services. If requesting a denial based on coverage by a managed care plan, submit the claim as covered without condition code 04 or 69.

  • If the beneficiary is enrolled in a managed care plan for only a portion of an inpatient stay, submit the claim as follows:

    IPPS IPF IRF LTCH CAH Non-IPPS SNF/SB
    • If Medicare is primary upon admission, bill the entire claim to Medicare.
    • If the managed care plan is primary upon admission, bill the entire claim to the managed care plan.
    • Bill the managed care plan for days the patient is enrolled in the managed care plan.
    • Bill Medicare for the days the patient is not enrolled in the managed care plan.

    Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1External PDF, section 90

  • If the beneficiary is enrolled in a managed care plan and elects the hospice benefit, all hospice and non-hospice related services beginning on the date of the hospice election are billed to Medicare as follows:
    • Hospice services covered under the Medicare hospice benefit are billed by the hospice provider to the Home Health and Hospice (HH&H) Medicare Administrative Contractor (MAC).
    • Services provided by the enrollee's attending physician (if the physician is not employed by or under contract to the enrollee's hospice) are billed by the physician to Part B of the A/B MAC.
    • Services not related to the treatment of the terminal condition are billed by the provider to Part A of the A/B MAC with condition code 07.
    • Services furnished after the revocation or expiration of the enrollee's hospice election are billed accordingly until the full monthly capitation payments begin again. Monthly capitation payments begin on the first day of the month after the beneficiary revokes the hospice election.

Reference: CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 11External PDF, section 30.4

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