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J15 Part A Claims Processing Issues Log

Updated: 04.20.15

Listed below are current system-related claims processing issues that have been reported to the Centers for Medicare & Medicaid Services (CMS) and/or the Fiscal Intermediary Standard System (FISS) Maintainer. This information is made available and updated as we have new information or updates to share, so you may review prior to contacting the Part A Provider Contact Center. A list of resolved issues is also available at the end of this list. If you still have questions, please call 866.590.6703.

Reason Code/Status Location Situation Status
32511 Because of Direct Data Entry (DDE) screen changes implemented in CR 8950 and CR 8434, the NDC quantity and qualifier fields have changed. Ensure your software vendor makes changes or updates for the new layout of MAP171E in DDE. Claims are RTPing if NDC information is present on the claim but is missing one of the required elements (NDC, quantity qualifier, or quantity). 04.17.2015
There are 2 potential solutions for this issue: either enter the information in the RTP'd claim, or resubmit the claim after you have verified that your software vendor has implemented the correct field updates on MAP171E in DDE.
36602, 36381 Status Locations SMG279 and SMG280 HCPCS codes G0279 and G0280 are not pricing when submitted on claims. 04.17.2015
There are ongoing issues with the pricing of the codes. CMS has advised contractors to continue to hold claims until further notice.

Claims with HCPCS codes G0279 or G0280 will be suspended in location SMG279 and SMG280 until the FISS April Quarterly Release, scheduled to go into production on 04.06.15, is implemented. There is no workaround. Once the release is implemented, suspended claims will be released by CGS.
37096 (IRF PAI) Some IRF claims are receiving reason code 37096, even though the PAI has been submitted timely to QIES. 04.17.2015
CGS was only able to identify a very limited number of claims that returned in error and that issue was forwarded to CMS/FISS to be researched. However, since the volume of claims affected is very low, the issue will not be given a high priority for resolution.

The majority of claims reviewed edited correctly. Therefore, providers are encouraged to review both the information submitted to QIES and on the claim to ensure the information is correct, matches and was submitted timely. If an error is identified (in QIES or on the claim), correct it and resubmit/F9 the claim. Please review the following article to ensure each element is addressed prior to resubmitting your claim: Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF – PAI), referenced by SE1342External PDF. Refer to Submission Date and Claims Processing: Scenarios.

For further assistance on reports and important information, refer to Attachments # 1 and #2 on pages 5 and 6 of SE1342.

NOTE: Even though the QIES Assessment shows "Accepted” on the report, it does not signify that all the required data is present and matches.

The issue is still being researched.  In the interim, providers should review their claims to ensure that the correct information has been submitted to QIES and submitted timely. If one of the issues is found, providers should submit the correct the information and resubmit to QIES and F9 the claim to CGS. Reminders are listed in the article Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF – PAI), referenced by SE1342External PDF. Refer to Submission Date and Claims Processing: Scenarios.

CGS is in the process of researching the issue.
55503, 54500 Some Mammography claims were submitted with covered ICD-9 codes, in accordance with our Local Coverage Determination (LCD), but were denied incorrectly. 12.19.2014
The number of claims identified that were denied in error was small. These claims will be manually adjusted by CGS.

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