Part B Family Practice Common Rejections and
Description: Part B Family Practice Common Rejections and Denials June 2024 Disclaimer We prepared this education as a tool to assist the provider community. Medicare rules change often. They are in the relevant laws, regulations and rulings on the
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slide1. Part B Family Practice Common Rejections and Denials June 2024<br>
slide2. Disclaimer We prepared this education as a tool to assist the provider community. Medicare rules change often. They are in the relevant laws, regulations and rulings on the Centers for Medicare & Medicaid Services (CMS) website.
We will provide responses to questions based on the facts given, but the Medicare rules will determine final coverage.Â
CMS prohibits recording of the presentation for profit-making purposes.<br>
slide3. Agenda Provide details on common rejections and denials for specialty type 08 (family practice) providers
Focus on data for 1500 claim form or 837P electronic claim submission
Speaker will provide details on
Common rejections and denials
How to fix and avoid both
Resources
Questions<br>
slide4. Life of a Claim<br>
slide5. Batch Rejection<br>
slide6. Claim Submission Submit electronically
Use 999 report to confirm claim receipt
Use 277 report for more specific information
Find information in the Medicare 276/277 Companion Guide
Clarifies, supplements, and further defines data content requirements
Correct or resubmit<br>
slide7. Unprocessable Rejection<br>
slide8. Rejection versus Denial Rejection Unprocessable
Returned on the “front end
Missing or incorrect information
No appeal rights; resubmit the service
MA130 and CO16 codes on remittance advice
Patient not liable Denial Adjudicated
Fails to meet payment criteria
Statutory requirements
Medical necessity/frequency
Eligibility
MA01 code on claim provides appeal rights
Patient liability determined<br>
slide9. Processed<br>
slide10. Remittance Advice (RA) Provides claim adjudication information to provider
Includes information about
Adjustments
Denials
Missing items
Refunds
Offsets Two formats
Electronic Remittance Advice (ERA)
Standard Paper Remittance (SPR)<br>
slide11. Claim Adjustment Reason and Remark Codes Claim Adjustment Reason Codes (CARCs) explain why a claim paid differently than billed
Remittance Advice Remark Codes (RARCs) provide more details about an adjustment described by a CARC<br>
slide12. Claim Adjustment Group Codes Assign financial liability for unpaid portion of claim balance
CO – Contractual Obligation – provider liable
PR – Patient Responsibility<br>
slide13. Code Maintenance Washington Publishing Company (WPC) maintains codes for CMS
Find link to code lists on WPC website<br>
slide14. RA – Learn More Health Care Payment and Remittance Advice and Electronic Funds Transfer (EFT)
Operating Rules EFT and Remittance Advice<br>
slide15. Correct or Appeal<br>
slide16. Potential Actions to Choose Rejections
Fix the error, resubmit the service
Denial
Fix the error, resubmit the service, when available
Clerical Error Reopening (CER) process
Use portal when available
Appeal
Request a redetermination<br>
slide17. Clerical Error Reopening (CER) Process to correct human or mechanical errors
Limited to only certain acceptable clerical error submissions
Use portal or submit request via telephone or fax
Submit within one year of RA receipt date
Learn more
How to Request a Clerical Error Reopening (CER)<br>
slide18. Appeals Five levels
MACs render only level one redeterminations
All levels have time limits to file the request
Time limits for completion also apply
Amount in Controversy (AIC) threshold applies only for
Level three (Administrative Law Judge Hearing)
Level five (Federal Court Review)<br>
slide19. Appeals Resources How to Appeal a Claim Determination
CMS Fee-for-Service (FFS) Appeals Process Flowchart
Updated annually<br>
slide20. Data Dashboard<br>
slide21. Data All states in MAC Jurisdictions 5 and 8
Specialty 08 (family practice)
Submission dates 10/01/23 – 03/31/24
Data last refreshed on 04/10/24<br>
slide22. Common Rejections by Reason Denied – rendering physician #invalid/missing. Submit a new claim – 18,676
Claim lacks information needed for adjudication – 7,931
Missing/incomplete/invalid ordering primary identifier – 6,537
Denied – Invalid or missing modifier – 2,642
Claim must be submitted to RRB – 2,117<br>
slide23. More Common Rejections by Reason Denied – Field 11 of HCFA 1500 must be completed – 1,878
Missing procedure modifier(s) – 1,708
Denied – CLIA number is invalid or missing – 896
The hospital should bill Medicare Part A for this service – 860
Place of service conflicts with procedure code. Submit new claim – 846<br>
slide24. Common Rejections by HCPCS/CPT Code 36415
80053
85025
99214
80061 83036
84443
G0439
20610
99499<br>
slide25. Common Denials by Reason Duplicate charge paid ?002XX on claim ?001XXXXXXXXXX – 23,400
Collection of fee-for-service during periods of managed care – 22,705
Duplicate charge of claim ?001XXXXXXXXX now being processed – 10,430
Separate payment not made for this service. Do not bill patient. – 8,531
Payment included in another service received on same day – 7,483<br>
slide26. More Common Denials by Reason This is a duplicate charge – 7,250
Claim must be sent to EGHP first – 7,071
Denied service/units of service are exceeded – 5,084
Not cov when perf/refer/ordered by this provider – 4,370
These services are denied because the patient is in a hospice – 3,288
The time limit for filing your claim has expired. No appeal right – 3,251<br>
slide27. Common Denials by HCPCS/CPT Code 99214
99213
82962
G0439
36415 83036
36416
G2211
G0444
99232<br>
slide28. Claims Dashboard – Further Breakdown of Data State by reason
County by reason
State by HCPCS code
County by HCPCS code
Trending<br>
slide29. Data Trends Code Description – AWV G0439 within 12 months of G0438 or G0439
Claim Count Current Three Months – 375
Claim Count Three Months Prior – 408
Difference in Number of Claims – -33
Percentage Change – -8%
Difference Claims Change – Decrease (Arrow down)<br>
slide30. Resources<br>
slide31. Requirements for Medicare Claims CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 26 – Completing and Processing Form CMS-1500 Data Set
CMS 1500 to ANSI 837 5010 Crosswalk<br>
slide32. Website Resource – Rejections How to Correct a Rejected Claim explains how to identify and correct an unprocessable claim
Listed by remark codes<br>
slide33. Website Resource – Denials Common Claim Denials suggests actions to take to avoid common reasons for denials
Listed by reason and remark codes for these categories
Bundling
Duplicate claim/service
Global surgery rules
Entitlement denials
Payer/Contractor denials
Provider number denials<br>
slide34. WPS GHA Resources WPS GHA website
Medicare Secondary Payer (MSP) Questions and Answers
WPS GHA Live Events web page
WPS GHA Encore Presentations web page
WPS GHA LCD & Article Lookup tool
WPS GHA YouTube Channel
Includes global surgery and evaluation and management selections<br>
slide35. More WPS GHA Resources Modifiers
Place of Service Codes for Professional Claims
Proper Billing for Various Medicare Advantage HMO Claims
Freedom of Information Act (FOIA)
We Want to Partner with You
Code Lookup Tool on website home page
Enter code, title, or definitions to search for Local Coverage Determinations (LCDs) & Articles or National Coverage Determinations (LCDs)<br>
slide36. CMS Website Resources Medicare Coverage Database (MCD)
National searchable depository of national and local coverage determinations, articles, and more
How to Use the Medicare Coverage Database MLN educational tool
CLIA Program & Medicare Lab Services Fact Sheet
Beneficiary Notices Initiative (BNI)
Links to Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN) instructions and forms<br>
slide37. More CMS Website Resources Contractor Directory – Interactive Map
Medicare National Correct Coding Initiative (NCCI) Edits
Includes links to Medicare NCCI Procedure to Procedure (PTP) Edits and Medicare NCCI Medically Unlikely Edits
Medicare Advantage Resources
Reference Guide for Medicare Physicians & Supplier Billers Part B
Includes ordering and referring details<br>
slide38. Interactive Voice Response (IVR) System Check eligibility, find claim status and details
24 hours a day, 7 days a week
Limited functionality outside normal business hours
Use voice or telephone keypad
Instructions in IVR Operating Guide<br>
slide39. WPS GHA Portal Log in to check eligibility, claim status, claim details and claim actions
24 hours a day, 7 days a week
Limited functionality outside normal business hours
Instructions in Portal User Manual<br>
slide40. Questions<br>
slide41. Thanks for Attending<br>
slide2. Disclaimer We prepared this education as a tool to assist the provider community. Medicare rules change often. They are in the relevant laws, regulations and rulings on the Centers for Medicare & Medicaid Services (CMS) website.
We will provide responses to questions based on the facts given, but the Medicare rules will determine final coverage.Â
CMS prohibits recording of the presentation for profit-making purposes.<br>
slide3. Agenda Provide details on common rejections and denials for specialty type 08 (family practice) providers
Focus on data for 1500 claim form or 837P electronic claim submission
Speaker will provide details on
Common rejections and denials
How to fix and avoid both
Resources
Questions<br>
slide4. Life of a Claim<br>
slide5. Batch Rejection<br>
slide6. Claim Submission Submit electronically
Use 999 report to confirm claim receipt
Use 277 report for more specific information
Find information in the Medicare 276/277 Companion Guide
Clarifies, supplements, and further defines data content requirements
Correct or resubmit<br>
slide7. Unprocessable Rejection<br>
slide8. Rejection versus Denial Rejection Unprocessable
Returned on the “front end
Missing or incorrect information
No appeal rights; resubmit the service
MA130 and CO16 codes on remittance advice
Patient not liable Denial Adjudicated
Fails to meet payment criteria
Statutory requirements
Medical necessity/frequency
Eligibility
MA01 code on claim provides appeal rights
Patient liability determined<br>
slide9. Processed<br>
slide10. Remittance Advice (RA) Provides claim adjudication information to provider
Includes information about
Adjustments
Denials
Missing items
Refunds
Offsets Two formats
Electronic Remittance Advice (ERA)
Standard Paper Remittance (SPR)<br>
slide11. Claim Adjustment Reason and Remark Codes Claim Adjustment Reason Codes (CARCs) explain why a claim paid differently than billed
Remittance Advice Remark Codes (RARCs) provide more details about an adjustment described by a CARC<br>
slide12. Claim Adjustment Group Codes Assign financial liability for unpaid portion of claim balance
CO – Contractual Obligation – provider liable
PR – Patient Responsibility<br>
slide13. Code Maintenance Washington Publishing Company (WPC) maintains codes for CMS
Find link to code lists on WPC website<br>
slide14. RA – Learn More Health Care Payment and Remittance Advice and Electronic Funds Transfer (EFT)
Operating Rules EFT and Remittance Advice<br>
slide15. Correct or Appeal<br>
slide16. Potential Actions to Choose Rejections
Fix the error, resubmit the service
Denial
Fix the error, resubmit the service, when available
Clerical Error Reopening (CER) process
Use portal when available
Appeal
Request a redetermination<br>
slide17. Clerical Error Reopening (CER) Process to correct human or mechanical errors
Limited to only certain acceptable clerical error submissions
Use portal or submit request via telephone or fax
Submit within one year of RA receipt date
Learn more
How to Request a Clerical Error Reopening (CER)<br>
slide18. Appeals Five levels
MACs render only level one redeterminations
All levels have time limits to file the request
Time limits for completion also apply
Amount in Controversy (AIC) threshold applies only for
Level three (Administrative Law Judge Hearing)
Level five (Federal Court Review)<br>
slide19. Appeals Resources How to Appeal a Claim Determination
CMS Fee-for-Service (FFS) Appeals Process Flowchart
Updated annually<br>
slide20. Data Dashboard<br>
slide21. Data All states in MAC Jurisdictions 5 and 8
Specialty 08 (family practice)
Submission dates 10/01/23 – 03/31/24
Data last refreshed on 04/10/24<br>
slide22. Common Rejections by Reason Denied – rendering physician #invalid/missing. Submit a new claim – 18,676
Claim lacks information needed for adjudication – 7,931
Missing/incomplete/invalid ordering primary identifier – 6,537
Denied – Invalid or missing modifier – 2,642
Claim must be submitted to RRB – 2,117<br>
slide23. More Common Rejections by Reason Denied – Field 11 of HCFA 1500 must be completed – 1,878
Missing procedure modifier(s) – 1,708
Denied – CLIA number is invalid or missing – 896
The hospital should bill Medicare Part A for this service – 860
Place of service conflicts with procedure code. Submit new claim – 846<br>
slide24. Common Rejections by HCPCS/CPT Code 36415
80053
85025
99214
80061 83036
84443
G0439
20610
99499<br>
slide25. Common Denials by Reason Duplicate charge paid ?002XX on claim ?001XXXXXXXXXX – 23,400
Collection of fee-for-service during periods of managed care – 22,705
Duplicate charge of claim ?001XXXXXXXXX now being processed – 10,430
Separate payment not made for this service. Do not bill patient. – 8,531
Payment included in another service received on same day – 7,483<br>
slide26. More Common Denials by Reason This is a duplicate charge – 7,250
Claim must be sent to EGHP first – 7,071
Denied service/units of service are exceeded – 5,084
Not cov when perf/refer/ordered by this provider – 4,370
These services are denied because the patient is in a hospice – 3,288
The time limit for filing your claim has expired. No appeal right – 3,251<br>
slide27. Common Denials by HCPCS/CPT Code 99214
99213
82962
G0439
36415 83036
36416
G2211
G0444
99232<br>
slide28. Claims Dashboard – Further Breakdown of Data State by reason
County by reason
State by HCPCS code
County by HCPCS code
Trending<br>
slide29. Data Trends Code Description – AWV G0439 within 12 months of G0438 or G0439
Claim Count Current Three Months – 375
Claim Count Three Months Prior – 408
Difference in Number of Claims – -33
Percentage Change – -8%
Difference Claims Change – Decrease (Arrow down)<br>
slide30. Resources<br>
slide31. Requirements for Medicare Claims CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 26 – Completing and Processing Form CMS-1500 Data Set
CMS 1500 to ANSI 837 5010 Crosswalk<br>
slide32. Website Resource – Rejections How to Correct a Rejected Claim explains how to identify and correct an unprocessable claim
Listed by remark codes<br>
slide33. Website Resource – Denials Common Claim Denials suggests actions to take to avoid common reasons for denials
Listed by reason and remark codes for these categories
Bundling
Duplicate claim/service
Global surgery rules
Entitlement denials
Payer/Contractor denials
Provider number denials<br>
slide34. WPS GHA Resources WPS GHA website
Medicare Secondary Payer (MSP) Questions and Answers
WPS GHA Live Events web page
WPS GHA Encore Presentations web page
WPS GHA LCD & Article Lookup tool
WPS GHA YouTube Channel
Includes global surgery and evaluation and management selections<br>
slide35. More WPS GHA Resources Modifiers
Place of Service Codes for Professional Claims
Proper Billing for Various Medicare Advantage HMO Claims
Freedom of Information Act (FOIA)
We Want to Partner with You
Code Lookup Tool on website home page
Enter code, title, or definitions to search for Local Coverage Determinations (LCDs) & Articles or National Coverage Determinations (LCDs)<br>
slide36. CMS Website Resources Medicare Coverage Database (MCD)
National searchable depository of national and local coverage determinations, articles, and more
How to Use the Medicare Coverage Database MLN educational tool
CLIA Program & Medicare Lab Services Fact Sheet
Beneficiary Notices Initiative (BNI)
Links to Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN) instructions and forms<br>
slide37. More CMS Website Resources Contractor Directory – Interactive Map
Medicare National Correct Coding Initiative (NCCI) Edits
Includes links to Medicare NCCI Procedure to Procedure (PTP) Edits and Medicare NCCI Medically Unlikely Edits
Medicare Advantage Resources
Reference Guide for Medicare Physicians & Supplier Billers Part B
Includes ordering and referring details<br>
slide38. Interactive Voice Response (IVR) System Check eligibility, find claim status and details
24 hours a day, 7 days a week
Limited functionality outside normal business hours
Use voice or telephone keypad
Instructions in IVR Operating Guide<br>
slide39. WPS GHA Portal Log in to check eligibility, claim status, claim details and claim actions
24 hours a day, 7 days a week
Limited functionality outside normal business hours
Instructions in Portal User Manual<br>
slide40. Questions<br>
slide41. Thanks for Attending<br>