Corporate

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.

August 2019

# of Kentucky RTPs # of Ohio RTPs Description Resource/Reference

20,583

53,233

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

5,479

12,855

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
  • NOTE: Don't forget about the Medicare Beneficiary Identifier (MBI)!

4,874

11,920

Missing/Incomplete/Invalid Patient Identifier

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

  • The Medicare Identifier (either the Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN)) is a Medicare beneficiary's identification number, used for processing claims and determining eligibility for services across multiple entities
  • Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 mandates removal of the Social Security Number (SSN)-based HICN from Medicare cards
  • Legislation requires that CMS mail new Medicare cards with a new MBI by April 2019
  • Transition period will run April 1, 2018 through December 31, 2019
    • Providers may submit either the MBI or HICN during the transition period
  • Several tools are available to make sure you obtain the MBI

NOTE: Please do not assume the patient's social security number with an 'A' suffix is the HICN. Always bill using the Medicare ID and name on the red, white, and blue Medicare card.

4,417

10,687

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 just began October 15th. Make sure your patients have not changed from traditional Medicare to one of the Medicare Advantage (MA) plans!

4,776

4,737

Referral Absent or Exceeded

Service requires ordering/referring provider to be reported on the claim

  • Entered in the electronic equivalent of box 17 and-17b of the CMS-1500 Claim Form
  • Review the CMS-1500 Claim Form / ANSI Crosswalk Job AidPDF for help identifying the fields
  • If information was reported on the claim, verify the physician/practitioner is of a specialty legally allowed to order/refer services for Medicare patients
  • Also verify ordering/referring physician/practitioner is enrolled in PECOS

Was this page helpful? YES NO


Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved