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.

October 2018

# of Kentucky Denials # of Ohio Denials Description Resource/Reference
38,718 92,128 Duplicate Service

Duplicate claims must be avoided:

  • 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.
24,631 95,054 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 began. Keep track of changes your patients may make from traditional Medicare to one of the Medicare Advantage (MA) plans for 2019!

16,899 43,844 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.

13,934 36,015 Payment is Included in Another Service Previously Adjudicated

Edits prevent our system from paying services that may be included in other services.

  • 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
11,534 29,355 Medicare is the Secondary Payer

When Medicare is secondary, the primary payer must be billed first

  • Check this article for steps to help you with MSP claims
  • 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
20,973 19,850 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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