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J15 Part A Claims Processing Issues Log

Updated: 07.21.14

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 on a weekly basis 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
31164 Effective July 1, 2014, for claims with dates of service on or after 01.01.14, providers should use Type of Bill 13X with Modifier L1 when non-referred lab tests are eligible for separate payment under the Clinical Laboratory Fee Schedule (CLFS). 07.10.2014
13X claims submitted with HCPCS modifier L1 were RTPd in error when submitted based on guidance issued in SE1412. CGS has implemented the CMS instruction to correct this issue. Providers can now F9 their RTPd claims to allow them to continue processing, or resubmit as new claims.
55503, 54500 Some claims for Polysomnography and Sleep Studies were submitted with covered ICD-9 codes, in accordance with our Local Coverage Determination (LCD), but are denying incorrectly. 07.21.2014
Providers should review the Polysomnography and Sleep Studies LCD to ensure that claims have denied in error.


CGS is aware that some claims for Polysomnography and Sleep Studies continue to deny incorrectly. CGS is currently working on the issue, and expects to identify all claims denied in error and will reprocess them accordingly.

CGS is in the process of identifying the affected claims and will reprocess the incorrectly denied services. We have made corrections in our claims processing system as of 06.25.14, and any claims submitted after this date are being processed correctly.
U5450 – U5454 Some outpatient therapy claims are receiving various RTPs/rejections incorrectly from the Common Working File (CWF) related to the functional therapy reporting requirements. 07.16.2014
CMS made several system modifications on May 5th in response to the many inquiries regarding Therapy Functional Reporting (THFR), and they believe this significantly reduced the number of THFR claim rejections. Providers who believe that their previous claims were erroneously returned for THFR issues should resubmit those claims for re-processing.


Providers should still verify that they are billing according to the information published in SE1307, and the article posted on the CGS website, Functional Reporting for Outpatient Therapy Services: Reminders.

This problem was reported to CWF. CWF is working with the CMS on a resolution.
U6805, U6806 Certain MSP Claims are suspending incorrectly. 07.21.2014
The issue with MSP claims receiving reason codes U6805 and U6806 in error was corrected in the July 2014 release.

The issue with certain MSP claims receiving these reason codes in error is expected to be fixed in early July with implementation of the July 2014 release.

In addition to information and instructions below, providers are encouraged to refer to CGS's web article Reason Code U6805: Clarification and Instructions.

There appears to be a small subset of claims that are RTPing incorrectly for Reason Code U6805. CGS is currently researching the issue and attempting to establish a process for preventing this.

Providers are still encouraged to verify that claims are being submitted correctly, and should refer to SE1416 for guidance on open MSP records.

The correction for U6826 has been implemented and claims are being released.

Reason code U6806 is being researched.

FISS has identified the issue for U6826, and a correction is tentatively scheduled in late April, 2014.
U538H Incarcerated beneficiary claim denials 05.22.2014
Adjustments have been completed and any suspended claims related to these adjustments are being worked.

Claim adjustments are tentatively scheduled in April 2014.

Providers that received refunds should have received a check and spreadsheet by the middle of December 2013. If providers feel they should have received a refund and did not, contact the Part A PCC to determine if a spreadsheet was sent and not received. If so, a duplicate spreadsheet will be sent within 48 hours.

To reconcile the RA, access the claims listed in the spreadsheet in DDE to obtain the individual claim amount. The total of the individual claims may not equal the total check amount on the spreadsheet since other offsets may have occurred. After research, if you cannot determine the claim information for the offsets or you have specific questions, you may contact the Part A PCC at the number listed above.

Please refer to the updated CMS Incarcerated Beneficiary FAQs for updated information: CMS FAQs

Please refer to the updated CMS Incarcerated Beneficiary FAQs for updated information: CMS FAQs

At this time, CGS has not received further official direction from CMS on this issue. Please refer to the CMS Incarcerated Beneficiary Claim Denial FAQs for information on common questions: CMS FAQs

Providers and suppliers should not resubmit claims. CMS is working diligently to develop a process to automate the reprocessing of the claims that were denied in error, and resubmitted claims complicate the solution.

As of 08.15.2013, claims will suspend to SMOSUK until we receive further instructions from CMS. We are also awaiting instructions for claims that denied prior to 08.15.2013.

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