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Claim Payment Alerts
Please reference this page for information about confirmed, system-related issues before you reach out to Customer Service. Click on the description to view details and check back often for updates that we post when they become available.
Closed issues remain on the active log for approximately 60 days before they move to the resolved issues archive list at the bottom of the page.
If you still have questions, please contact Customer Service or use one of our self-service tools.
| Date Reported |
Description of Issue |
| 11.07.2025 |
Reason Code U5233: The Common Working File (CWF) Host identified an issue that caused a subset of HMO beneficiary claims to deny (no open HMO enrollment) in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Part A |
U5233 |
|
|
| MAC Action |
Suspend claims until the issue is resolved. |
| Provider Action |
N/A |
| Proposed Resolution |
CGS will provide updates once the CWF Host notifies us that the issue is resolved. |
|
| 10.01.2025 |
Reason Code C7252: Claims for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) visits at a Skilled Nursing Facility (SNF) rejected in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
RHC & FQHC |
C7252 |
- TOB 71X or 77X
- Date of service on or after 07.01.2025
- Receipt date on or after 08.01.2025
|
|
| MAC Action |
CGS will identify and reprocess claims within 45 days. |
| Provider Action |
No provider action. |
| Proposed Resolution |
A system fix was installed on 10.06.2025. |
|
| 09.03.2025 |
Reason Code 39930: Rural Health Clinic (RHC) claims billed with Care Coordination Services received this edit in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
RHC |
39930 |
TOB 71X with Care Coordination Services |
10.06.2025 |
| MAC Action |
N/A |
| Provider Action |
No provider action. |
| Proposed Resolution |
10.06.2025 – A system fix was installed, and claims were released for processing.
09.03.2025 – Reason Code 39930 suspends claims when the claim level coinsurance due (Value Code A2) amount doesn't equal the sum of the line level coinsurance amounts.
Claims will remain in suspense until a fix is installed. A fix is tentatively scheduled with the October 2025 release. |
|
| 08.11.2025 |
Reason Codes 31006 & 31007: Some Critical Access Hospital (CAH) Method II professional services rejected because the physician doesn't have a reassignment on file in PECOS. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
TOB 85X |
31006, 31007 |
Dates of service on or after July 1, 2025; revenue codes 096X, 097X, or 098X |
|
| MAC Action |
- Turn off reason codes 31006 & 31007 through December 31, 2025.
- Adjust impacted claims to generate payment for the professional services.
|
| Provider Action |
An Office of Inspector General (OIG) audit (A-06-21-05003) identified that:
- Both CAHs and practitioners received payment for the same professional services.
- Practitioners billed for services after they reassigned their billing rights to a CAH.
Change Request (CR) 13900 created edits to prevent such duplicate billing. Effective for dates of service on or after July 1, 2025, reason code 31006 or 31007 will assign on CAH Method II (TOB 85X) claim lines for professional services (revenue code 096X, 097X, or 098X) when:
- The Attending or Rendering Physician NPI doesn't have a reassignment on file in PECOS.
- Or, the line level date of service on the claim doesn't fall within the physician's reassignment effective and term dates in PECOS.
Action: Ensure your providers submit their reassignment applications (CMS-855I) in PECOS for processing before January 1, 2026. See Part B Provider Enrollment for additional information. |
| Proposed Resolution |
Temporarily turn off reason codes 31006 & 31007 to give providers additional time to submit their reassignment applications. |
|
| 07.29.2025 |
Reason Code W7113: Some claims returned to provider (RTP'd) in error |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Outpatient TOBs except 12X & 22X |
W7113 |
Supplementary or additional code not allowed as principal diagnosis code |
|
| MAC Action |
CGS will suspend claims to apply a workaround until the issue is resolved |
| Provider Action |
If you identify RTP claims, please F9 or resubmit for CGS to apply the workaround. |
| Proposed Resolution |
A system correction is planned for a future quarterly release. |
|
Updated: 11.14.2025