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Reason Code Search and Resolution

Disclaimer: This is not a complete listing of reason codes.

The Reason Code Search and Resolution tool allows you to view a reason code description and determine how to prevent/resolve the edit. You may search by reason code or keyword. All records matching your search criteria will be returned for your review. You may also select "Show all Reason Codes" to view the complete list.

If the reason code you enter does not display here, you may access any reason code description in the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) Reason Codes Inquiry Menu (Option 17). For additional information, please reference the FISS DDE User Manual.

We also welcome your feedback. Requests to add or clarify information provided in this tool may be submitted to: J15_PartA_Education@cgsadmin.com.

Reason Code

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

Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.

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