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J15 Part A Claims Processing Issues Log

Updated: 08.07.14

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 SE1412External PDF. 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. 08.07.2014
Claims that denied incorrectly have been identified and will either be mass adjusted or reopened. The anticipated date for completion is by the end of September.  Providers that know certain claims were denied in error are encouraged to allow the claims to be adjusted and not send in appeal requests.

Providers should review the Polysomnography and Sleep StudiesExternal Website LCD to confirm 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 SE1307External PDF, 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.

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