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Claim Submission Error (CSE) Data

Claim Submission Errors (CSEs) result from an editing process that returns electronic and paper claims to the provider as "unprocessable." This occurs if the claim contains incomplete or invalid information. 

Returning a claim as "unprocessable" does not mean CGS will physically return every claim you submit with incomplete or invalid information. The term "Return to Provider" or "RTP" is used to refer to the many processes utilized by CGS for notifying you that your claim cannot be processed. The MA130 remark code on the remittance advice (RA) identifies an RTP claim/service.

RTP claims/services have no Appeal rights, as no "initial determination" can be made on an unprocessable claim/service due to the invalid or incomplete information submitted. This means that these claims cannot be corrected through Redeterminations, the first level of the appeals process. In addition, RTP claims/services do not qualify for correction through the Reopenings process. The error(s) found on these claims/services must be corrected and then resubmitted as NEW claims.

Please note that RTP claims/services create unnecessary costs to the Medicare program so should be avoided.

Below is a list of the monthly top RTP error categories. Refer to resources available to you to avoid future billing errors.

April 2020

# of Kentucky RTPs # of Ohio RTPs Description Resource/Reference
13,302 29,672 Procedure Code Invalid on Date of Service

Code claims using current CPT and HCPCS manuals

  • Codes are valid January - December of each year
  • HIPAA requires the use of codes valid the year the service is rendered
11,050 31,069 Invalid Procedure Code/Modifier Combination

When using a modifier, it must be one that is valid with the procedure code.

  • If service requires a modifier, verify that the correct one is used by accessing the Modifier Finder Tool  
  • The patient's medical record must support the use of a modifier

The Provider Contact Center (PCC) cannot tell you which modifier to use on a claim, as they do not have your medical records to determine whether the modifier is appropriately documented.

If you need help avoiding rejections, view this recorded webinar on modifier rejectionsExternal Website .

3,864 9,541 Missing/Incomplete/Invalid Patient Identifier

Be sure to include the correct patient identifier on your claims.

  • The Medicare Beneficiary Identifier (MBI) is the identification number used for processing claims and determining eligibility for services across multiple entities.
  • Use the myCGS MBI Look-Up Tool to obtain a patient's MBI

NOTE: Always bill using the Medicare ID and name on the red, white, and blue Medicare card.

3,506 7,998 Patient Medicare Identifier / Name Mismatch

Submit the patient's name and Medicare ID as it appears on their Medicare card

  • Patient must contact Social Security to make corrections/changes to Medicare card
  • HIPAA does not allow us to verify Medicare IDs
1,725 8,607 Missing/Incomplete/Invalid Group Practice Information

When an individual NPI is reported on a claim, the group NPI is required

  • Verify that the correct group National Provider Identifier (NPI) is reported on the claim
  • Enter information in the electronic equivalent to Item 33 and 33a of the CMS-1500 Claim Form
  • Review the CMS-1500 Claim Form / ANSI Crosswalk Job AidPDF for help identifying the fields

The practice location information is required as well.

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