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September 17, 2014

Reason Code 38119: Preventing Claim Submission Errors

One of the top reasons SNF claims are “returned to provider” (RTP’d) is reason code 38119, which means the claim submitted out of sequence and we have not received the claim immediately before this claim was submitted.

Claim Submission Guidelines

Medicare guidelines require SNFs to submit bills in sequence for each beneficiary. This means that when the beneficiary in the SNF as an inpatient for several months in a row, the claims for the subsequent months the beneficiary is in the SNF must be submitted one at a time, in sequential order. The subsequent claims in the stay should not be submitted until the prior month’s claim has been processed and finalized.

Example

Beneficiary A is in the SNF from March 1 through May 31, 2014; this is considered a continuing stay.

Submit the March claim, and allow that claim to finalize.
After the March claim has finalized, the claim for April services can be submitted. Allow the April claim to finalize before submitting the claim for May.
Submitting the April claim before the March claim has been submitted and allowed to process will cause the April claim to get reason code 38119.

Preventing Delays in Payment for Reason Code 38119
To ensure that your claims don’t RTP with reason code 38119, ensure that the prior month’s claim in a continuing stay has been submitted and has finalized. The most common scenario to cause this reason code is when the claim for the prior month in a continuing stay has not been submitted.

The claim for the prior month must be submitted AND finalized before you submit a claim for the next month. Check the status of your submitted claims through Direct Data Entry (DDE), the Interactive Voice Response (IVR) line, or through the myCGS web portal.
Monitor your RTP’D claims carefully; most have RTP’d as a result of a preventable error.
Ensure that new billing staff at your facility is aware of the requirements for sequential billing.

Reference

CMS Medicare Claims Processing manual (PUB. 100-04), chapter 6, section 40.1 and 40.2

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Reason Code 38119: Preventing Claim Submission Errors

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