Claim Payment Alerts
Date Reported | Provider Type Impacted | Reason Codes | Claim Coding Impact | Description of the Issue | Action Required by the MAC | Action Required by the Provider | Proposed Resolution/Fix | Status | Date Resolved |
---|---|---|---|---|---|---|---|---|---|
02/16/2024 |
Suppliers that submit claims for HCPCS codes A4238 and A4239 where the number of units billed denied because the medical necessity for the quantity has not been established. |
151 |
A4238 and A4239 |
Claims for dates of service 01/31/2024 and after for codes A4238 and A4239 are denying in error due to the number of units billed. |
CGS will reprocess claims that denied in error with ANSI Remark Code N115: Number of units billed denied because the medical necessity for this quantity has not been established. |
No action needed. |
Claims denied in error will be adjusted and preventative measures are being established. |
In progress: Several phases of adjustments will be necessary to complete reprocessing of claims. Estimated time of final claim adjustments is scheduled forĀ 04/21/2024. |
TBD |
11/06/2023 |
Suppliers who submit claims to the DME MAC when the from date of service equals the date of discharge from home health services and the beneficiary is no longer a patient. |
97 |
Home Health Consolidated Billing for the following: Urological, Ostomy, Tracheostomy, Surgical Supplies. |
This issue affects claims with dates of service on and after 01/01/2022 in which the date of service equals the date of discharge from home health services and the beneficiary is no longer a patient. These claims may be denying incorrectly for a home health episode. |
Claims with incorrect denials will be adjusted when brought to the DME MACs attention via a redetermination request. |
If the denial is incorrect, submit a redetermination for correction. |
Editing will be corrected at the Common Working File, (CWF) to prevent the incorrect denials and recoupments. |
In Progress |
TBD |
02/01/2019 |
Suppliers of HCPCS codes E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070 |
96 |
E1007, E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070 |
Claims for HCPCS codes E1020, E1028, E2228, E2368, E2369, E2370, E2375, K0015 and K0070 may have denied incorrectly due to a system processing issue. NOTE: This is an ongoing issue with no ETA for resolution. |
The issue causing the claim processing error cannot be corrected at this time. |
No action required. |
A report will be run monthly and claims will be adjusted if the denial was incorrect. |
NA |
NA |
02/01/2019 |
Suppliers of wheelchair accessories. |
151 |
Wheelchair accessory HCPCS codes. |
Claims for wheelchair accessories may have denied as same or similar equipment incorrectly due to a system processing issue. NOTE: This is an ongoing issue with no ETA for resolution. |
The issue causing the claim processing error cannot be corrected at this time. |
No action required. |
A report is run monthly, and claims are adjusted if the accessories were denied incorrectly. |
NA |
NA |