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Top Claim Submission Errors for Home Health Providers: Error U5233 and 7CS21

Reason for error: Dates of service billed are within a beneficiary Medicare Advantage (MA) plan enrollment period; therefore, no Medicare payment can be made.

Claim processing result: Reject

How to prevent/resolve:

  • Review the information on the Medicare Advantage (MA) Plans — Claim Filing Tips When A Beneficiary Receiving Home Health Services Enrolls / Disenrolls Web page.
  • Upon admission for Medicare-covered services, review all insurance (including Medicare Part D) cards the beneficiary has and verify the information on the card is valid.
  • Upon admission and prior to billing CGS, verify whether an MA plan will impact the dates of service by checking the beneficiary's eligibility file.  This information is available in the myCGS "Plan Coverage" tab.  It can also be found on the "PLAN INFORMATION" screen found on ELGA Page 1 and/or ELGH page 5.
  • See the CGS Checking Beneficiary Eligibility Web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.
  • Since MA plan election records are updated the first part of each month, providers whose dates of service span two consecutive months or extend beyond 30 calendar days are encouraged to check MA plan information for the beneficiary monthly.
  • Review the "Bill Code" field on the myCGS "Plan Coverage" tab or the OPT field on the ELGA page 1 and/or ELGA page 5  to determine where the claim needs to be sent for payment.
    • If the OPT code or bill code is a 'C', the MA plan is responsible for processing the claim.
      • According to the Medicare Claims Processing Manual, (CMS Pub. 100-04, Ch. 11, §30.4External PDF), "While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS." In addition, "…the duration of payment responsibility by fee-for-service contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiaries. MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked."
    • If the OPT or bill code is a '1', services may be submitted to CGS for processing.
  • The myCGS "Plan Coverage" tab will display the MA Plan’s name, identifier, and contact information.  If using ELGA/ELGH or the plan name and contact information is not available in myCGS, access the MA Claims Processing ContactsExternal Websitedirectory, which contains a list of all active Medicare contracts and their corresponding plan type.
  • If the MA plan election is posted to the beneficiary's eligibility file in error, the MA plan will need to correct this information. Providers should contact the MA plan directly to update the beneficiary's record.
    • Providers should be aware that until the beneficiary's eligibility file is updated, any claims submitted to CGS will be impacted by the incorrect MA plan information; therefore, providers should not submit Medicare claims until the MA plan information is corrected.
  • If the MA plan election was correctly posted to the beneficiary's file and impacts your dates of service, you must look to the MA plan for reimbursement of services. Do not submit billing transactions to CGS for payment, unless the eligibility file indicates the fee-for-service (FFS) contractor is responsible for processing the beneficiary's Medicare claims or there is a hospice election that impacts the MA plan enrollment period and your services are unrelated to the hospice election.

Updated: 05.15.13

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