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J15 Part A Resolved Claims Issues

Updated: 06.21.17

Reason Code/Status Location Situation Status
Reject Code 36342 Reject code 36342 was set up to claim level reject ESRD claims instead of line level reject in error. 03.01.2017
The reason code was corrected on January 25, 2017 to line level reject correctly. If there are claims that rejected the entire claim prior to January 25, 2017, providers may adjust the rejected claims either electronically or through DDE.
Reason Code 34943 Some ESRD claims (72X type of bill) were RTP'd in error due to an issue with the system edit. 02.06.2017
This issue is resolved. If there are claims that are not processing as they should, notify the PCC at the number listed above.

01.19.2017
This issue has been addressed. However, if you identify additional claims in RTP status with reason code 34943, F9 or resubmit the claims for correct processing.
U6833/SM6833

U6832/SM6832
CGS has determined that there are claims that have RTP'd in error with reason code U6833/U6832.

This reason code states that "Medicare is billed as secondary payer due to a non-GHP; however, there is no matching diagnosis(es) on the claim and the non-GHP record(s) on CWF."
01.19.2017
CGS is submitting Electronic Correspondence Referral System (ECRS) requests to the Benefits Coordination & Recovery Contractor (BCRC) on these claims. Providers can expect 30 days for normal claims processing time. Remarks on the claim will indicate that an ECRS has been submitted.

12.12.2016
CGS is aware of the issue and is working on a resolution. If you have claims that you believe are RTP'd in error, F9 the claims or resubmit, and the claims will be suspended until the correction is implemented.
W7099/SM7099 13X type of bill claims were erroneously receiving reason code W7099 in one statutory exception.

Section 1861(s)(2)(I) of the Act provides Medicare coverage of blood clotting factors for hemophilia patients competent to use such factorsto control bleeding without medical supervision, and items related to the administration of such factors.
01.19.2017
These issues have been resolved.

11.03.2016
Claims receiving this reason code in error are being suspended until the January 2017 Integrated Outpatient Code Editor (IOCE) is implemented.

If there are claims that are RTP'd in error, F9 and resubmit, and claims will be suspended until the correction is implemented.

NOTE: There was an additional issue with W7099 editing incorrectly on non-OPPS claims. CMS and FISS have provided a work around for this issue. If you have claims RTP'd in error, F9 those claims for the work around to be applied.
Reason Code C7251 Claims are denying in error stating that services were within a Skilled Nursing Facility (SNF) stay when there is no SNF stay indicated on the Common Working File (CWF). 09.27.2016
This issue has been resolved.

07.18.2016
The CWF has responded that reason code C7251 is setting when a prior SNF claim has discharge status of 30 (still a patient) on the claim. The prior claim will need to be corrected to indicate the correct discharge status code before the claim receiving C7251 can process.

06.23.2016
CGS is still actively working with the CWF to resolve the issue.
Reason Code C7252 Claims are denying or being recouped in error because of incorrect editing at the CWF. 11.03.2016
This issue has been resolved.

09.27.2016
Mass adjustments were completed in July 2016.

06.23.2016
CGS has implemented a correction for claims rejected incorrectly for reason code C7252 as of June 14, 2016. Claims rejected with C7252 in error prior to June 14, 2016 will be adjusted by CGS to pay correctly. Adjustments should be completed by mid-September.

05.23.2016
CGS will create a work-around in FISS to override the C7252 response for lines containing revenue code 0510 and HCPCS G0463. CGS will also adjust claims denied in error.

05.10.2016
CGS is aware of the issue and is communicating with the Fiscal Intermediary Standard System (FISS) maintainer and the CWF to resolve the issue.
Certain claims that include a covered ICD-10 diagnosis code based on the LCD were medically denied in error with reason code 55503. Certain claims that include a covered ICD-10 diagnosis code based on the LCD were medically denied in error with reason code 55503. 09.27.2016
This issue is resolved.

05.24.2016
When using the appeals process, ensure that you submit records/documentation with your appeal.

05.12.2016
Adjustments to the following types of claims which denied incorrectly for the LCD have been completed:
  • Mammography
  • Sleep Studies
  • Bone Mass Measurement
  • Vascular Studies


Should you have claims with denials that were not adjusted and you disagree with the denial, please follow the appeals process.

CGS continues to work diligently to review the remainder of our LCDs. CGS advises providers to not let their appeal rights expire if they disagree with any denial.

04.28.2016
CGS is in the process of adjusting claims that denied in error prior to 03.01.16. Claims received after 03.01.16 will need to be appealed if providers disagree with the denial.

Reminder: The correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the determination.

03.30.2016
CGS is aware that there continues to be issues with claims and adjustments denying incorrectly with reason code 55503. Internal discussions are ongoing. Any additional information or resolutions will be communicated via this CPIL as it is received.

02.24.2016
CGS has completed the LCD edit revalidation, and expects all adjustments to correct the incorrectly denied services to be completed by March 1, 2016.

If providers see any denials after March 1, 2016, they should follow the appeals process as all LCD edits have been revalidated.

01.28.2016
Additional mammography claims that were medically denied in error have been identified and are being adjusted.

The vascular study adjustments have been completed and are being verified.

CGS has reviewed all LCD edits and the edits are being revalidated. Remaining claims that were medically denied in error will be adjusted by the end of February 2016.

Again, as a reminder, contact the PCC if you are unsure if the denials are in error. Use the appeals process if you are unsure to prevent the timeframe expiring.

01.21.2016
Affected mammography claims have been adjusted. Other affected LCDs and claims that may have been affected are still being actively researched.

As a reminder, contact the PCC if you are unsure if the denials are in error. Use the appeals process if you are unsure to prevent the timeframe expiring.

12.04.2015
Medically reviewed claims denied in error are still being adjusted. As a reminder, contact the PCC if you are unsure if the denials are in error, and use the appeals process if needed.

11.23.2015
This issue has been corrected and claims denied in error will be adjusted. All other medical denied claims will need to be appealed as usual.

Adjustments will begin processing the week of November 23rd.

If providers are unsure if their denials are due to the issue or not, please contact the PCC to verify.

If a specific ICD-10 diagnosis is not listed on an LCD, and providers believe it should be, email CMD.Inquiry@CGSAdmin.com. These inquiries will be reviewed on a case by case basis and a response will be received from the CMD Inquiry.
Reason Codes 59182, 59183, 59112-59115 CMS and CGS are aware that some claims may be denying incorrectly in relation to NCD 20.4 with the listed reason codes. 05.12.2016
The issue has been resolved and all suspended claims have been released.

03.02.2016
CGS will suspend the potential affected claims to location SM5DEF until the issue has been resolved. These claims will be set to suspend to prevent the claims from continuing to deny in error. Once the edit is working correctly, CGS will release the suspended claims so that they will edit with the corrected logic.

If your claims have denied with one of the reason codes, and you are unsure whether it denied incorrectly, you are advised to submit an appeal.
Location SMOLDX CGS identified an issue that caused some MolDX claims to inappropriately suspend for review with reason code 58888. 05.24.2016
Resolved.

02.24.2016
This issue has been resolved.

Claims currently suspended to this location that do not contain a MolDx ID in the remarks field will be reviewed to ensure coverage criteria is met. Claims that have suspended incorrectly are being released.
Skilled Nursing Facility (SNF) are not pricing correctly on or after 10.01.15 date of service. CGS has received clarification from CMS and the SNF Provider Specific Files are being updated. 05.11.2016
Issue is resolved.

02.24.2016
Due to the volume of claims requiring adjustments, CGS is still in the process of adjusting the affected claims.

01.21.2016
All updates have been completed as of mid-December, 2015. Affected claims are currently in the process of being adjusted, with an anticipated completion date of mid-February.

12.04.2015
Once the update is completed, SNF claims that paid incorrectly will be adjusted.
Healthcare Common Procedure Coding System (HCPCS) codes C9453, C2623, C9449, C9450, C9454, and C9455. Healthcare Common Procedure Coding System (HCPCS) codes C9453, C2623, C9449, C9450, C9454, and C9455. 05.11.2016
Issue is resolved.

01.28.2016
Files have been corrected and/or updated as of January 27, 2016. If you have claims with HCPCS that have RTP'd for this reason, F9 or resubmit the claim(s). If you have omitted the HCPCS because the file was not correct, adjust the claim and add the HCPCS.

01.21.2016
CGS is actively updating affected files. Once the files are updated, CGS will notify providers via this CPIL.

When charges are submitted after the correction has been made, indicate in Remarks section of the claim that the timeliness is due to a file issue, if the claim is not timely.

11.23.2015
There are ongoing issues with some HCPCS in certain regions. The CPIL will be updated once the issue is resolved.

10.20.2015
The issue has been resolved for claims in the KY and OH region for HCPCS C9453. The issue has been resolved for claims in the KY region for HCPCS C2623.

Providers may F9 or resubmit claims that are RTP'd in error for these HCPCS/regions.

Once the issue is resolved for HCPCS C2623 for the OH region, the CPIL will be updated and providers may F9 or resubmit those claims.
Location SM5KEY CGS has identified an issue with Medical Review claims suspending incorrectly in the system. 05.11.2016
Issue is resolved.

01.21.2016
Suspended claims in this location are still actively being processed, and the volume has been reduced significantly.

11.20.2015
Claims suspended in SM5KEY are still actively being worked.

01.21.2016
Suspended claims in this location are still actively being processed, and the volume has been reduced significantly.

11.20.2015
Claims suspended in SM5KEY are still actively being worked.
36602, 36381 Status Location SMG279 HCPCS code G0279 (diagnostic digital breast tomosynthesis, unilateral or bilateral) is not pricing when submitted on claims 05.11.2016
Issue is resolved.

01.21.2016
CGS is in the process of adjusting claims affected by this issue.

07.02.2015
It has been determined that the July release will not fully correct the problems associated with the claims. CMS has instructed CGS to release the held claims, process them and append condition code 15. When the correction is implemented in January 2016, the claims will be adjusted to process and pay correctly.

05.27.2015
A tentative correction date is scheduled when the July release is implemented. Suspended claims will be released to process.

05.15.2015
There are still issues with pricing of the codes.

04.17.2015

There are ongoing issues with the pricing of the codes. CMS has advised contractors to continue to hold claims until further notice.

03.04.2015
Claims with HCPCS codes G0279 or G0280 will be suspended in location SMG279 and SMG280 until the FISS April Quarterly Release, scheduled to go into production on 04.06.15, is implemented. There is no workaround. Once the release is implemented, suspended claims will be released by CGS.
HCPCS 77063 – screening digital tomosynthesis Outpatient claims (Type of Bill 12x and 13x) submitted with screening digital tomosynthesis (HCPCS) 77063 are not pricing based of the Medicare Physician Fee Schedule (MPFS) when billed correctly. 10.28.2015
Resolved.

10.19.2015
The correction was implemented in the October release, and CGS will adjust claims brought to their attention.

05.27.2015
A tentative correction date is scheduled to correct the issue when the October release goes into production on October 5, 2015. CGS will mass adjust claims or adjust claims brought to their attention.
32511 Because of Direct Data Entry (DDE) screen changes implemented in CR 8950 and CR 8434, the NDC quantity and qualifier fields have changed. Ensure your software vendor makes changes or updates for the new layout of MAP171E in DDE. Claims are RTPing if NDC information is present on the claim but is missing one of the required elements (NCD, quantity qualifier, or quantity). 05.15.2015
Resolved. Providers should correct claims in RTP status, and communicate changes to their vendor.

04.17.2015
There are 2 potential solutions for this issue: either enter the information in the RTP'd claim, or resubmit the claim after you have verified that your software vendor has implemented the correct field updates on MAP171E in DDE.
37096 (IRF PAI) Some IRF claims are receiving reason code 37096, even though the PAI has been submitted timely to QIES. 05.13.2015
Resolved. Providers who have issues with information submitted correctly in QIES are instructed to contact resources indicated in SE1342.

04.17.2015
CGS was only able to identify a very limited number of claims that returned in error and that issue was forwarded to CMS/FISS to be researched. However, since the volume of claims affected is very low, the issue will not be given a high priority for resolution.

The majority of claims reviewed edited correctly. Therefore, providers are encouraged to review both the information submitted to QIES and on the claim to ensure the information is correct, matches and was submitted timely. If an error is identified (in QIES or on the claim), correct it and resubmit/F9 the claim. Please review the following article to ensure each element is addressed prior to resubmitting your claim: Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF – PAI), referenced by SE1342External PDF. Refer to Submission Date and Claims Processing: Scenarios.

For further assistance on reports and important information, refer to Attachments # 1 and #2 on pages 5 and 6 of SE1342.

NOTE: Even though the QIES Assessment shows "Accepted" on the report, it does not signify that all the required data is present and matches.

03.31.2015
The issue is still being researched. In the interim, providers should review their claims to ensure that the correct information has been submitted to QIES and submitted timely. If one of the issues is found, providers should submit the correct the information and resubmit to QIES and F9 the claim to CGS. Reminders are listed in the article Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF – PAI), referenced by SE1342External PDF. Refer to Submission Date and Claims Processing: Scenarios.
55503, 54500 Some Mammography claims were submitted with covered ICD-9 codes, in accordance with our Local Coverage Determination (LCD), but were denied incorrectly. 05.13.2015
All affected claims have been adjusted.

01.16.2015
CGS is in the process of researching the issue.

12.19.2014
The number of claims identified that were denied in error was small. These claims will be manually adjusted by CGS.
55503, 54500 Some claims for Polysomnography and Sleep Studies were submitted with covered ICD-9 codes, in accordance with our Local Coverage Determination (LCD), but were denied incorrectly. 12.08.2014
All affected claims should have been adjusted.

11.07.2014
All affected claims have been adjusted.

10.22.2014
Unfortunately, CGS is still having issues with adjusting claims for sleep studies that were denied in error. Providers do have the option of submitting Redetermination requests for any claims you believe were denied in error for this reason. If you are submitting a Redetermination request past the timeframe for filing a first-level appeal (i.e., more than 120 days from the date of the initial determination), we strongly recommend you provide supporting documentation for "late filing" with your request and reference the CGS Claims Processing Issues Log. As a reminder: registered users can file electronic Redetermination requests through our secure web portal, myCGS. You may also complete the redetermination formPDF by electronically completing each field, then print the form, sign it, attach supporting documentation, and mail it.

09.30.2014
Due to an issue with the FISS mass adjustment process, the adjustments for the Sleep Studies have not been completed as anticipated. CGS is expecting a correction to the process and will have the adjustments completed by mid-October.

08.07.2014
Claims that denied incorrectly have been identified and will either be mass adjusted or reopened. The anticipated date for completion is by the end of September. Providers that know that claims were denied in error are encouraged to allow the claims to be adjusted and not send in appeal requests.

07.21.2014
Providers should review the Polysomnography and Sleep StudiesExternal website LCD to confirm that claims have denied in error.

07.16.2014
CGS is aware that some claims for Polysomnography and Sleep Studies continue to deny incorrectly. CGS is currently working on the issue, and expects to identify all claims denied in error and will reprocess them accordingly.

07.08.2014
CGS is in the process of identifying the affected claims and will reprocess the incorrectly denied services. We have made corrections in our claims processing system as of 06.25.14, and any claims submitted after this date are being processed correctly.
U5450, U5451, U5452, U5453, U5454 Some outpatient therapy claims are receiving various RTPs/rejections incorrectly from the Common Working File (CWF) related to the functional therapy reporting requirements. 12.08.2014
All outpatient therapy claim issues should be resolved.

11.07.2014
Issue is expected to be fully resolved 11.10.14.

09.23.2014
CMS made additional system modifications for U5452 to assist in the reduction of the number of THFR claim rejections. As a reminder, providers should review MLN Matters article SE1307External PDF to verify that they have billed correctly. Providers may F9 and/or resubmit the claim after they have ensured the claim was billed correctly.

07.16.2014
CMS made several system modifications on May 5th in response to the many inquiries regarding Therapy Functional Reporting (THFR), and they believe this significantly reduced the number of THFR claim rejections. Providers who believe that their previous claims were erroneously returned for THFR issues should resubmit those claims for re-processing.

03.21.2014
Providers should still verify that they are billing according to the information published in SE1307External PDF, and the article posted on the CGS website, Functional Reporting for Outpatient Therapy Services: Reminders.

This problem was reported to CWF. CWF is working with the CMS on a resolution.
7PET1-7PET8 CGS will hold certain claims for FDG Pet Scans for Solid Tumor for dates of service 10.06.14 – 11.10.14, as mentioned in CR 8739, dated April 18, 2014. 12.08.2014
All affected claims have been released.

11.07.2014
Claims with HCPCS Code A9952 will continue to be held in status/location SMHPET until 11.30.14.

The other status/locations have been released.

10.01.2014
Claims will be suspended in locations SMPET1 – SMPET 7, and SMMPET, and released on 11.11.14.
31099 Type of Bill 18X (swing bed) is receiving reason code 31099 in error when patient status code 30 is on the claim. 12.08.2014
Issue has been resolved.
37015 (pricer return code 65) and 37001 (pricer return code 52) An issue with the 2015 Inpatient Prospective Payment System (IPPS) Pricer is causing inpatient claims with discharge dates on/after 10/1/2014 to suspend. 12.08.2014
Issue has been resolved.

11.07.2014
CMS and the FISS System Maintainer are aware of the issue and research is being conducted.

11.07.2014
Issues with return codes 65 and 52 to be corrected on 11.10.14. Additional issues with the Pricer still need to be corrected.

11.03.2014
This issue has been reported to CMS. We anticipate this will be resolved in mid-November 2014.
31164 Effective July 1, 2014, for claims with dates of service on or after 01.01.14, providers should use Type of Bill 13X with Modifier L1 when non-referred lab tests are eligible for separate payment under the Clinical Laboratory Fee Schedule (CLFS). 09.05.2014
Resolved

07.10.2014
13X claims submitted with HCPCS modifier L1 were RTPd in error when submitted based on guidance issued in SE1412External PDF.

CGS has implemented the CMS instruction to correct this issue. Providers can now F9 their RTPd claims to allow them to continue processing, or resubmit as new claims.
U6805, U6806 Certain MSP Claims are suspending incorrectly. 08.07.2014
This issue has been resolved.

06.24.2014
The issue with certain MSP claims receiving these reason codes in error is expected to be fixed in early July with implementation of the July 2014 release.

06.02.2014
In addition to information and instructions below, providers are encouraged to refer to CGS's web article Reason Code U6805: Clarification and Instructions.

05.07.2014
There appears to be a small subset of claims that are RTPing incorrectly for Reason Code U6805. CGS is currently researching the issue and attempting to establish a process for preventing this.

Providers are still encouraged to verify that claims are being submitted correctly, and should refer to SE1416External PDF for guidance on open MSP records.

05.01.2014
The correction for U6826 has been implemented and claims are being released.

04.04.2014
Reason code U6806 is being researched.

03.21.2014
FISS has identified the issue for U6826, and a correction is tentatively scheduled in late April, 2014.
U538H Incarcerated beneficiary denials 08.07.2014
This issue has been resolved.

05.22.2014
Adjustments have been completed and any suspended claims related to these adjustments are being worked.

04.04.2014
Claim adjustments are tentatively scheduled in April 2014.

02.13.2014
Providers that received refunds should have received a check and spreadsheet by the middle of December 2013. If providers feel they should have received a refund and did not, contact the Part A PCC to determine if a spreadsheet was sent and not received. If so, a duplicate spreadsheet will be sent within 48 hours.

To reconcile the RA, access the claims listed in the spreadsheet in DDE to obtain the individual claim amount. The total of the individual claims may not equal the total check amount on the spreadsheet since other offsets may have occurred. After research, if you cannot determine the claim information for the offsets or you have specific questions, you may contact the Part A PCC at the number listed above.

12.06.2013
Please refer to the updated CMS Incarcerated Beneficiary FAQs for updated information: CMS FAQs

11.22.2013
Please refer to the updated CMS Incarcerated Beneficiary FAQs for updated information: CMS FAQs

11.15.2013
At this time, CGS has not received further official direction from CMS on this issue. Please refer to the CMS Incarcerated Beneficiary Claim Denial FAQs for information on common questions: CMS FAQs

08.30.2013
Providers and suppliers should not resubmit claims. CMS is working diligently to develop a process to automate the reprocessing of the claims that were denied in error, and resubmitted claims complicate the solution.

08.23.2013
As of 08.15.2013, claims will suspend to SMOSUK until we receive further instructions from CMS. We are also awaiting instructions for claims that denied prior to 08.15.2013.
39011, 39012 Certain A/B rebilling claims will RTP in error due to an issue with the April quarterly release. 07.11.2014
Issue was resolved.

06.24.2014
The issues with certain claims receiving these reason codes in error is expected to be fixed in early July with implementation of the July 2014 release.

06.17.2014
There continue to be issues with certain claims receiving reason codes 39011 and 39012 for claims with dates of service on/after 10.01.13.
Issues with reason codes 31795 and 31824 have been resolved.

06.02.2014
There are still issues with certain claims receiving reason codes 31795, 39011, 39012, and 31824.

Until further notice, claims receiving certain reason codes in error will be held in the following locations:
  • If reason code 31795 is received in error, claims will be held in location SMCLM2.
  • If reason codes 39011 or 39012 are received in error, claims will be held in location SMCLM8.
  • If reason code 31824 is received in error, claims will be held in SMCLMA.
4.21.2014
CMS has instructed contractors to suspend claims that receive these reason codes in error beginning April 7, 2014. Claims will be held in locations SMCLM1-SMCLM6 until a fix is successfully implemented into production. A fix is tentatively scheduled in late April 2014.
31796, 31797, 31818, 34910, and 39015 Certain A/B rebilling claims will RTP in error due to an issue with the April quarterly release. 06.02.2014
Issues with reason codes 31796, 31797, 31818, 34910, and 39015 have been resolved.
MSP Relationship MSP claims with a patient relationship of 18 are not populating on the Standard Paper Remittance (SPR) correctly. The primary insured name is indicated rather than the Medicare beneficiary that is covered under the spousal benefits. 06.30.2014

The correction for dates of service prior to the fix was implemented in early June.

05.22.2014
The correction for dates of service going forward has been implemented.
39910 An issue has been identified for claims that received reason code 39910 and meet the following criteria:
  • Type of Bill = 14X
  • Submitted by a Critical Access Hospital
Dates of service on or after April 1, 2013
05.22.2014
The fix was implemented and affected claims have been released.

04.04.2014
CMS has instructed contractors to suspend these claims beginning April 7, 2014. Claims will be held in location SMCLM7 until a fix is successfully implemented into production. A fix is tentatively scheduled in May 2014.
7OPPS Claims that meet the following criteria will RTP with reason code 7OPPS due to an issue with the OPPS Pricer Update:
  • 12X and 13X claims for HCPCS codes J1446 and J7178 for dates of service on and after January 1, 2014.
12X and 13X claims for HCPCS code A9545 for dates of service on and after April 1, 2014.
05.01.2014
Resolved – Claims have been released.

04.04.2014
CMS has instructed contractors to suspend these claims. Claims will be held in location SMCLM9 until a fix is successfully implemented into production. A fix is tentatively scheduled in late April 2014.
WW999 Claims for services paid under the Medicare Physician Fee Schedule (MPFS) for dates of service on or after April 1, 2014 04.21.2014
Resolved – Claims have been released.

CMS has instructed contractors to suspend claims until April 14, 2014. Claims will be held in location SMFISS. Additional information is available in the CMS Provider Education Message published on March 28, 2014.
31276-31277 Several diagnosis codes are included in both the ICD-9 and ICD-10 code files. Therefore, claims submitted with those ICD-9 codes are receiving reason codes 31276 and 31277 for ICD-10 editing. 04.11.2014
Resolved

04.04.2014
Claims held in location SMHICD for reason codes 31274-31277 have been released.

03.28.2014
Claims are currently suspending in location SMHICD. If you have claims that are in RTP status with reason codes 31274-31277, verify the diagnosis codes on the claim, then F9.

This issue has been reported to the FISS system maintainer and to CMS.
31824 Hospitals were advised to hold certain A/B Rebilling outpatient claims. 03.21.2014
The correction was implemented and claims are processing correctly.

03.07.2014
The system correction will go into production on 03.10.14. Providers should submit held claims, or F9 claims with these criteria that are in RTP status with reason code 31824.

02.21.2014
Due to a systems problem affecting the processing of A/B rebilling outpatient claims, hospitals should wait until March 10, 2014 to submit claims that meet all of the following criteria:
  • 12x or 13x Type of Bills
  • Treatment Authorization Field: A/B Rebilling
  • Condition Code: W2
  • Discharge date: After the rebilling termination date
  • Overlaps processed inpatient claims that contain: Claim status R and occurrence span code 77 or M1.
Once the correction goes in, providers may submit the held claims or F9 claims that are in RTP status.
U6805 Medicare Secondary Payer (MSP) claims are processing incorrectly due to changes implemented in CMS Change Request (CR) 7605 on January 7, 2013. 01.17.2014
Resolved

12.06.2013
Providers should continue to verify MSP records and refer to the CMS MLN Matters article SE1416External PDF.

11.15.2013
Reminder: verify MSP records prior to submitting claims to ensure correct claim processing. Please refer to CMS MLN Matters article SE1416External PDF for more information regarding issues with the COBC. This article replaces SE1205, and indicates the name change from COBC to Benefits Coordination and Recovery Center (BCRC).

10.25.2013
A workaround has been made available for U6825. CGS continues to research the other issues noted below.

10.18.2013
Reason code U6802 has not been identified as an issue. Providers are encouraged to review and correct/resubmit these claims.

Reason code U6805 has been identified as an issue and is being researched.

09.20.2013
Reason codes U6802 and U6805 are still being researched. Providers are encouraged to review claims that receive these edits and correct/resubmit claims that did not RTP in error.

08.02.2013
CWF has determined that reason code U6826 is editing correctly. Reason codes U6802 and U6805 are still being researched.

07.12.2013
Reason code U6826 is being researched by CWF. Reason codes U6802 and U6805 were previously listed but have been removed while we research to determine if these codes should also be reported.

06.28.2013
Reason codes U6802 and U6826 are being researched by FISS. Reason code U6805 has been removed; however, CGS will research to determine if it should also be reported to FISS.

06.14.2013
The issue is being researched by FISS.

05.17.2013
The issue has been reported and is being researched by CMS and the Common Working File (CWF).
39071, 39072, 39073 Medicare Secondary Payer (MSP) claims are rejecting with reason code 39071, 39072, or 39073 when a non-trauma diagnosis code is included on a liability, no-fault, or Workers' Compensation record in the Common Working File (CWF). 01.17.2014
Resolved

12.06.2013
Claims suspended in SMOSUF have been released, and CGS continues to monitor the claims.

10.25.2013
Claims are suspending to SMOSUF until further direction is received.

10.18.2013
The fix that went into production on 10.07.13 was unsuccessful and the issue is still being researched.

08.09.2013
A fix is tentatively scheduled on 10.07.13.

08.02.2013
CWF has determined that some claims are editing incorrectly. Claims will suspend to SMOSUH while the issue is being researched.

07.12.2013
Resolved. After further research, we have determined that this was not a Part A system issue and claims that were suspended to SMOSUG have been released. However, some claims may have rejected in error. You may review any rejected claims to determine the following:

If the claim contains a diagnosis code that matches a diagnosis listed on an open liability, no-fault, or Workers' Compensation (WC) record in CWF, the claim will reject.

If the claim contains a diagnosis code that matches a diagnosis listed on an open liability, no-fault, or WC record in CWF, but the services provided on the claim were not related to the liability, no-fault, or WC incident, you may adjust the claim and report condition code D9 and the following statement in the Remarks section: Not related to open MSP record.

If the claim contains a diagnosis code that matches a diagnosis listed on an open liability, no-fault, or WC record in CWF, but the diagnosis is a non-trauma diagnosis (e.g., diabetes, hypertension, etc.), you may contact the Part A PCC to have an Action Request submitted.

06.28.2013
The tentatively scheduled fix is for home health and hospice claims only. CGS will research claims rejecting with these reason codes to determine if this should be reported to FISS for Part A.

06.14.2013
A fix is tentatively scheduled on 10.07.2013.

05.10.2013
Claims have been set to suspend to SMOSUG while the issue is researched.

04.16.2013
You may contact the Part A PCC to have an Action Request submitted to determine if the diagnosis code(s) are related/unrelated to the MSP file. However, we are experiencing delays with the Action Requests due to a high volume of requests and a claim cycling issue that occurs after the MSP file is updated.
37015 Inpatient claims with a date of discharge on or after October 1, 2013, are receiving reason code 37015 in error due to an issue with the 2014 IPPS Pricer file. 11.15.2013
Resolved

11.9.2013
It has been verified that claims with dates of discharge prior to 10.1.13 were not impacted.

Claims for certain providers with discharge dates on or after 10.1.13 were RTP'd incorrectly with reason code 37015. Those claims have been corrected and put back into process with no intervention needed from providers.

Providers that have claims receiving RTPs with reason code 37015 with discharge dates prior to 10.1.13 will need to contact the PCC, as instructed in the reason code. Those claims were not corrected as they were not impacted by the change.

10.25.2013
CGS is researching this issue to determine whether claims with dates of discharge prior to 10.01.13 might also be impacted.

10.18.2013
This issue is being researched.
51MUE, 53MUE, 54MUE CMS instructed all Medicare contractors to hold claims that receive a Medically Unlikely Edit (MUE) due to a FISS system issue. 11.08.2013
Resolved.
10.25.2013
These claims have been released and are processing correctly.

09.06.2013
The MUE fix is in production, and is currently being reviewed to ensure claims are processing correctly.

08.23.2013
Claims that received reason code 53MUE will suspend to SM8023. A fix is tentatively scheduled on 09.01.2013.

08.02.2013
A fix for 53MUE is tentatively scheduled.

07.12.2013
Resolved. Claims that were suspended to SMOSU9 with reason codes 51MUE and 54MUE have been released and new claims are processing.

07.05.2013
The fix went into production on 07.01.13 and claims are being released.

06.14.2013
Claims will suspend to SMOSU9. A fix is tentatively scheduled to be implemented with the July 2013 release.
38013 Inpatient hospital claims are rejecting with reason code 38013 in error. This applies to the receiving hospital's same-day transfer claim. 10.18.2013
Resolved. A fix was successfully implemented on 10.07.2013.

06.28.2013
A fix is now tentatively scheduled for 10.07.2013.

06.14.2013
A fix is tentatively scheduled on 07.01.2013.

05.10.2013
The FISS Maintainer is researching and a fix is tentatively scheduled.
PB9996 Some claims are reaching the payment floor (PB9996) and not moving to the finalized location (PB9997). 06.28.2013
Resolved.We have confirmed that the fix was successful and all claims have finalized.

06.14.2013
A fix was implemented on 05.06.2013. We are researching to ensure all affected claims have finalized.

05.10.2013
A fix is in process.

01.30.2013
The Healthcare Integrated General Ledger Accounting System (HIGLAS) and Fiscal Intermediary Standard System (FISS) Data Centers are working to resolve the issue.
C7123 Skilled Nursing Facility (21X) and Swing Bed (18X) claims are rejecting with reason code C7123 in error when the correct occurrence span code 70 (hospital qualifying stay) date is reported. 05.10.2013
Resolved.CGS will release claims that were suspended. Otherwise, you may adjust any affected claims.

01.30.2013
This issue has been reported and a fix is being researched.
70034, 70038 Some claims were denied with reason codes 70034 and 70038 in error. 05.10.2013
Resolved.Claims have been adjusted.

01.30.2013
Claim adjustments for reason code 70034 are in process. Claim adjustments for reason code 70038 are complete.
E51#U Skilled Nursing Facility (21X) and Swing Bed (18X) claims are being returned to the provider (RTP'd) with reason code E51#U in error because FISS is changing the information reported for covered, non-covered, and coinsurance days and coinsurance amounts (value codes 80-82 and 09). 05.10.2013
Resolved.A fix was successfully installed into production on 01.07.2013.

01.30.2013
This issue is being researched by the FISS Maintainer and a fix is tentatively scheduled.

07.09.2012
This issue has been reported to the FISS Maintainer.
EA031 Inpatient claims are being returned to the provider (RTP'd) with reason code EA031 in error because FISS is removing condition code 04 from information only claims. 05.10.2013
Resolved.A fix was successfully installed into production on 01.07.2013.

01.30.2013
A fix is rescheduled on 01.07.2013.

11.21.2012
A fix is tentatively scheduled on 02.11.2013.
N5052 Claims for beneficiaries with a suffix after the name (i.e., Sr., Jr.) are being returned to the provider (RTP'd) with reason code N5052 in error because a comma is being applied in error. 05.10.2013
Resolved.A fix was successfully installed into production on 03.04.2013.

01.30.2013
This issue is being researched by the FISS Maintainer and CWF. You may manually remove the comma from the name and resubmit the claim.
SB0100 A large number of Ohio claims that were submitted electronically on 07.12.2012 were assigned the same Document Control Number (DCN 21219500000407OHA) and are in status location SB0100. 05.10.2013
Resolved.A fix was successfully installed into production on 01.28.13.

01.30.2013
This issue is currently being researched by the FISS Maintainer and a fix is tentatively scheduled.

09.25.2012
A fix was implemented on 09.04.2012 and all claims were released.

The remittance advice is a single, informational only, no-pay remit for each provider that contains the detail claim information and may be out of balance.

08.27.2012
This issue is currently being researched by the FISS Maintainer.
51MUE, 52MUE Certain services assigned a Medically Unlikely Edit (MUE) are denying with reason code 51MUE/52MUE in error due to a problem with the July 2011 system release. 01.30.2013
Resolved.Claim adjustments for claims processed between 07.05.2011 and 08.07.2011 are complete.

12.28.2013
CMS is testing system changes to perform an automated adjustment of these claims.
32907 Inpatient Part B ancillary (12X) claims are being returned to the provider (RTPd) with reason code 32907 in error. 12.05.2012
Resolved.CMS determined this is not a system problem and the issue has been closed.

Per CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 4, section 10.12External PDF: When there is no Part A coverage for an inpatient stay, there is no inpatient service into which outpatient services provided within the three-day/one-day payment window must be bundled. Therefore, services provided prior to the point of admission (i.e., the admission order) may be separately billed to Part B (13X) as the outpatient services that they were.

11.30.2012
The FISS Maintainer has scheduled a fix with the April 2013 release.
NCD edit Certain lab services are denying in error when the covered diagnosis code is reported in diagnosis code fields 11-25. 10.11.2012
Resolved.A fix was implemented on 10.01.2012.

08.27.2012
You may submit a claim adjustment to move the covered diagnosis code to diagnosis code fields 1-10 and include the following statement in the Remarks section: CPT XXXXX, Justifying Diagnosis is XXX.X. The adjustment claim will suspend with reason code 30940. Once a claim analyst verifies the diagnosis code was originally submitted in diagnosis code fields 11-25, the adjustment will be processed to pay the line that denied in error.

06.29.2012
A fix is scheduled for the October 2012 release. You should not submit diagnosis codes in diagnosis code fields 11-25 until the fix has been installed.
E461J Outpatient claims (12X, 13X, and 14X) are receiving reason code E461J in error. The deductible is being applied, but the expenses subject to the deductible field is blank. 10.04.2012
Resolved.A fix was implemented on 09.04.2012 and all claims have been released.

08.27.2012
A fix is scheduled on 09.04.2012. Affected claims are set to suspend with reason code E461J.
PB9996 Canceled claims are processing to status location PB9996 (payment floor) but a remittance advice is not produced since the claim is not finalized (PB9997). 10.04.2012
Resolved.A fix was implemented on 09.04.2012 and claims were released.

08.27.2012
A fix is scheduled with the September 2012 system release.

08.10.2012
This issue has been reported to the FISS Maintainer.
Procedure-to-Device edit Claims submitted with CPT code 33249 and HCPCS code C1882 are being returned to provider (RTPd) in error due to an error in the January and April 2012 procedure-to-device edit files. 07.31.2012
Resolved.A fix was implemented with the July 2012 system release and all claims have been released.

06.29.2012
The July 2012 Integrated Outpatient Code Editor (I/OCE) will be updated. Claims with dates of service 01.01.2012 through 06.30.2012 will suspend until the I/OCE is updated and installed on 07.02.2012.
31313 Medicare Secondary Payer (MSP) claims are being returned to the provider (RTPd) with reason code 31313 in error because the Release of Information (RI) field is populated incorrectly. 07.25.2012
Resolved.

06.29.2012
If you receive a timely filing edit, resubmit the claim with the following statement in the Remarks section: Claim affected by 31313 issue. Please override timely filing.

06.12.2012
This issue has been resolved. You may resubmit affected claims.

06.07.2012
A fix was implemented on 06.04.2012; however the issue is not resolved. The FISS Maintainer has been notified.

05.31.2012
A fix is tentatively scheduled on 06.04.2012.

05.18.2012
A fix is tentatively scheduled on 06.04.2012.

05.15.2012
This issue is still being researched and a fix is pending.

05.09.2012
The fix did not address all issues; therefore, the issue is still being researched.

03.22.2012
A fix was implemented and is being verified.

03.05.2012
The scheduled fix is ongoing. You may correct the RI field of the claim by changing "N" to "Y."
F5052 Inpatient and SNF claims are receiving reason code F5052 in error and continue to cycle due to an error in the Common Working File (CWF). 06.07.2012
CMS has fixed a system problem that delayed payment of some inpatient and SNF claims processed beginning April 2. Payments for affected claims have been processed.

05.18.2012
System changes have been made and claims are following the normal process. The CWF holds affected claims and recycles them in five working days for a response. If the response is present on the first recycle, the CWF will finish processing the claims according to the response. If the response is not present on the first recycle, please allow time for claims to move through the CWF.

05.15.2012
This issue has been reported for research.

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