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Claim Denial Data

Claims may be accepted as filed by Medicare systems but may be denied. CMS and CGS have established claim level editing to ensure services that should not be paid are appropriately denied. Many denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes.

Denials are subject to Appeal, since a denial is a payment determination. There are, however, some denials that can be avoided.

Below is a list of the monthly top denial reasons. Refer to resources available to you to avoid future denials.

August 2018

# of Kentucky Denials # of Ohio Denials Description Resource/Reference
40,753 83,626 Duplicate Service
  • Check the status of ALL claims before resubmitting
    • Use myCGSPDF to check the status of claims
    • The Interactive Voice Response (IVR)PDF is another option
      • Select option to check for additional claims with same date of service to locate the claim originally paid
  • Submit multiple same services provided on same date on ONE claim
  • Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
    • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
21,160 84,960 Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer.

NOTE: The Medicare open enrollment period recently ended. Make sure your patients have not changed from traditional Medicare to one of the Medicare Advantage (MA) plans!

15,865 41,619 Code Submitted is for Reporting Purposes Only

Some providers are REQUIRED to participate in quality reporting programs. One method of participating is to submit non-payable measures on claims along with payable CPT codes. The non-payable codes are captured by CMS or our processing system to determine whether the provider successfully reported. Initiatives in place include:

NOTE: Because reporting is a requirement, this denial is not one that can be avoided.

15,472 39,596 Payment is Included in Another Service Previously Adjudicated
  • Check definition of CPT/HCPCS codes to determine whether the code can be separately billed
  • Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services
  • The status of some CPT/HCPCS codes prevent them for being separately paid
    • Services with a status 'B' are always bundled, as payment is included in other services
10,703 25,509 Medicare is the Secondary Payer
  • When Medicare is secondary, the primary payer must be billed first
  • Refer to the MSP Job AidPDF to determine how a patient's record "should" appear
    • If the patient's record is different than what the flowchart suggests, please contact the Benefits Coordination and Recovery Center (BCRC)
  • Verify patient eligibility to determine whether there is a payer primary to Medicare
8,642 15,479 Provider not Certified/Eligible

All providers who serve Medicare patients are required to be enrolled in Medicare. 

Providers enrolled in Medicare will be required to revalidate their enrollment every five years. The Revalidation process requires providers to complete a new enrollment application. Applications not submitted timely result in suspension of the provider's billing privileges.

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