Transcript Slide 1

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Common Denials for
CMS-1500 Claims
Presented by
EDS Provider Field Consultants
October 2008
Agenda
• Session Objectives
• Edits and Audits Defined
• Edit and Audit Groups
• Types of Edits
• Types of Audits
• Top 10 Denials by Provider Type
• Top 25 Denials - Overview
• Helpful Tools
• Questions
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October 2008
Session Objectives
• Understand the different edit groupings
• Learn the purposes of edits and audits
• Develop knowledge on how to correct the claim
once the claim has denied
• Understand how to submit correct claims to
avoid edit denials
• Learn how to quickly research and correct
denied claims
– Reduce aged accounts
– Improve cash flow
• Answer your questions
• Provide avenues of resolution
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October 2008
Edits and Audits
• Edits - are designed to verify data submitted
on the claim form and ensure claims are
submitted with the necessary data to process
the claim
• Audits - are designed to compare the claim
being processed to the claims that have already
been paid (paid history)
• Edits and audits are designed to ensure claims
are paid within policies set forth by the Office
of Medicaid Policy and Planning (OMPP) and
Centers for Medicare & Medicaid Services
(CMS)
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October 2008
Edit and Audit Groups
• 0001-0499 Validation Edits
• 0500-0999 Relational Edits
• 1000-1999 Provider Edits
• 2000-2999 Recipient Edits
• 3000-3999 Prior Authorization (PA) Edits
• 4000-4999 Reference Edits
• 5000-5999 History Audits
• 6000-6999 Medical Policy
• 7000-7999 Surveillance and Utilization Review
(SUR) Edits
• 8000-8999 Pharmacy
• 9000-9999 Miscellaneous (informational) Edits
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October 2008
Types of Edits
• Validation Edits (EOB 0100 to 0499) - used to validate the
presence and format of data entered on the claim
Most Common: 0202 – Billing Provider I.D. in Invalid Format
• Relational Edits (EOB 0500 to 0899 and 8000 to 8999) -
used to compare or relate multiple fields on the current
claim
Most Common: 0558 – Coinsurance/Deductible Amount Missing
• Provider Edits (EOB 1000 to 1999) - are performed on the
provider identification numbers such as billing, rendering,
and referring Legacy Provider Identifier (LPI) and National
Provider Identifier (NPI)
Most Common: 1004 – Rendering Provider Not Eligible to
Render Service on DOS
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October 2008
Types of Edits
• Recipient Edits (EOB 2000 to 2999) - are performed on the
member identification number (RID) to ascertain member
eligibility
Most Common: 2017 – Recipient Ineligible on DOS Due to
Enrollment in a Managed Care Organization
• Prior Authorization Edits (EOB 3000 to 3999) - are performed
to ascertain that billed services which require prior
authorization are prior authorized
Most Common: 3001 – DOS Not on PA Master File
• Reference Edits (EOB 4000 to 4999) - check various reference
tables used in claims processing, such as formulary file,
procedure code table, modifier table and pricing table
Most Common: 4021 – Procedure Code Vs. Program Indicator
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October 2008
More Audits
• SURS Edits (EOB 7000-7999) - were established to
allow Surveillance and Utilization Review (SUR)
examiners to perform prepayment administrative
reviews on identified providers and recipients
 Most Common: 7002 – Claim Denied for DUR Reasons
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October 2008
Types of Audits
• History Related Audits (EOB 5000 to 5999) - compare the
current claim with paid claims in history to determine if a
claim is a duplicate of a previously paid claim
 Most Common: 5001 – Exact Duplicate
• Medical Policy Audits (EOB 6000 to 6999) - track and
restrict certain services based on eligibility and coverage
policy set forth by the OMPP and CMS
 Most Common: 6000 – Manual Pricing Required
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October 2008
Top 25 Denials – CMS-1500 Claims
October 2008
(1) Edit 0232
Rendering Physician Number Not in Valid Format
• The rendering physician LPI number is not in a
valid format on the CMS-1500 or dental claim
• The rendering LPI, if still submitted on the
claim, must be nine numeric characters
• Resubmit the claim with rendering NPI only, or
NPI and valid rendering LPI
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October 2008
(2) Edit 5001
Exact Duplicate
• Claim being processed is an exact
duplicate of a claim on the history file or
another claim being processed in the
same cycle
• Research prior claims billed for “paid”
status
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October 2008
(3) Edit 2017
Recipient Ineligible on Date of Service Due to Enrollment
in a Managed Care Organization
• The recipient was not eligible for the fee-for-
service medical assistance on the date of
service because they were enrolled in the riskbased managed care program
• The service should be billed to the appropriate
managed care organization
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October 2008
(4) Edit 0593
Medicare Denied Detail
• Denied detail lines must be re-billed separately
on a separate claim form
–Occur when Medicare denies a detail line
–Are not crossover claims
–Do not include the paid detail lines on the
new claim
–Processed as TPL claims
–Include the Medicare Remittance Notice
(MRN) with the claim
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October 2008
(5) Edit 0558
Coinsurance and Deductible Amount Missing
CMS-1500
-Field 22
Left = The sum amount for
Medicare Coinsurance,
Deductible and Psych
Reduction
Right = Medicare Paid Amount
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October 2008
(6) Edit 2505
Recipient Covered by Private Insurance (with Attachment)
• Include member identification on the claim
attachment
• Clearly state the reason for non-coverage on the
TPL attachment
• Ensure that the primary insurance company
name on the attachment matches the
information in the member’s file
• Hand write “Medicare replacement policy” on the
EOB, if applicable
• TPL listed is no longer valid
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October 2008
(7) Edit 4021
Procedure Code vs. Program Indicator
• Procedure code billed is restricted to a specific
program
– Package B
– Package C
– 590
• Verify eligibility prior to rendering service
• Submit claim with appropriate procedure code
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October 2008
(8) Edit 0219
Quantity Dispensed Is Missing
• Claims will deny if the quantity dispensed is
missing
• Include quantity dispensed and unit of measure
(EA, GM, ML)
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October 2008
(9) Edit 0810
NDC Unit Qualifier (Unit of Measure)
• Claims requiring a National Drug Code (NDC)
must have a unit qualifier (unit of measure)
• CMS-1500 – Field 24 a-h (shaded section)
–See Bulletin BT200713
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October 2008
(10) Edit 1003
Billing Provider Not Enrolled at Service Location for Date of Service
• Billing provider number is not enrolled in the
program on the date of service
–Verify the correct LPI was reported on the
claim
• To initiate a new enrollment
–Download the Provider Enrollment
Application via www.indianamedicaid.com
–Complete the form and submit to Provider
Enrollment
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October 2008
(11) Edit 0217
NDC Missing
• All claims requiring NDC information must have
NDC present on claim
• CMS-1500 – Field 24 a-h (shaded section)
–See Bulletin BT200713
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October 2008
(12) Edit 2502
Recipient Covered by Medicare Part B (No Attachment)
• If a physician or outpatient claim is submitted
for a Medicare Part B covered service and
recipient is covered by Medicare Part B
• Claim will deny if no attachment indicating Part
B has been billed
• Bill Medicare Part B first
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October 2008
(13) Edit 0268
Billed Amount Missing
• If the billed amount is missing for any detail
line, the claim will deny
• Verify each detail line has a billed amount
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October 2008
(14) Edit 2003
Recipient Ineligible on Date of Service
• The recipient was not eligible on the date of service
• Always verify eligibility on the date the member is seen
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October 2008
(15) Edit 1044
Care Select Member’s PMP Is Missing
• CMS-1500
–Field Locator 17b (NPI)
–Primary medical provider NPI and/or LPI is
missing/invalid on the claim form
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October 2008
(16) Edit 1004
Rendering Provider Not Eligible to Render Service on this
Program for the Date of Service
• Rendering provider number is not enrolled in
the specific program (for example, 590
Program) on the date of service
–Verify the rendering provider’s enrollment via
Web interChange
–If necessary, complete the Provider Update
Form to enroll the provider in the program
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October 2008
(17) Edit 1108
Billing NPI Has No Matching LPI
• The billing LPI and NPI are submitted on the
claim.
• The billing NPI does not crosswalk to an LPI in
the provider database
• Verify NPI is linked to the correct LPI
• Verify claim was billed with correct NPI/LPI
combination
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October 2008
(18) Edit 1042
Certification Code is Missing - Care Select
• The rendering provider is not the Care Select
member’s primary medical provider (PMP) and
there is no certification code on the claim
• CCF will be generated
• Resubmit claim with the referring PMP’s two-
digit certification code in block 19 of CMS-1500
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October 2008
(19) Edit 4209
No Pricing Segment for Procedure/Modifier Combination
• Applicable to medical claims reporting
processing and pricing modifiers
• Verify procedure/modifier combination is
reported correctly
–IHCP Fee Schedule
–IHCP Provider Manual
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October 2008
(20) Edit 0499
CCF Not Returned within 45 Days
• Examples of claims that will generate a CCF:
–Claims over one year old (0512)
–Certification code missing (Care Select)
–Claims that require attachments
• Sterilization consent form
• Periodontal Chart
• CCF will not print for:
–Electronic claims with attachments (Region
21)
Note: Electronic claims will remain in a CCF
status for 45 days, or until the attachment is
received
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October 2008
(21) Edit 1007
Rendering Provider Not on Provider Database
• The rendering provider in block 24j is not on
the provider database
• Verify the accuracy of the rendering provider
number
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October 2008
(22) Edit 1049
Care Select Member’s PMP Is Missing
• Provider specialty or procedure code on the
claim requires a referral from the PMP
• The rendering provider is not the member’s
PMP
• Claim must have the referring PMP provider
number in block 17a (LPI) or 17b (NPI)
• Claim must have referring PMP certification
code in block 19
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October 2008
(23) Edit 0513
Recipient Name and Number Disagree
• The recipient name and RID number on the
claim must match the recipient database
• Always verify eligibility on the date of service
• Verify recipient name and RID number
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October 2008
(24) Edit 3001
Date(s) of Service Not on PA Database
• Applies when the code billed requires Prior
Authorization (PA) for that program, and the
date(s) of service indicated on the claim do not
fall within the start/stop dates prior authorized
for that code
• Verify PA was approved via Web interChange or
Automated Voice Response (AVR) at (317)
692-0819 in the Indianapolis local area or 1800-738-6770 toll-free
• Contact HCE Prior Authorization Department at
(317) 347-4511 or toll-free at 1-800-457-4518
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October 2008
(25) Edit 1120
Rendering NPI Info Submitted Not Reported to an LPI
• The claim was submitted with rendering NPI
only, and the NPI is not reported to any LPI
• Report the rendering NPI
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October 2008
Helpful Tools
Avenues of Resolution
• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Customer Assistance
–1-800-577-1278, or
–(317) 655-3240 in the Indianapolis local area
• Written Correspondence
–P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
–View a current territory map and contact information
online at www.indianamedicaid.com
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October 2008
Questions
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October 2008
Presentation by EDS Provider Field Consultants
EDS
950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer
and values the diversity of its people. © 2008 Electronic Data Systems Corporation. All rights reserved.
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October 2008