J15 Part A Claims Processing Issues Log
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
||CGS will hold certain claims for FDG Pet Scans for Solid Tumor for dates of service 10.06.14 – 11.10.14, as mentioned in CR 8739, dated April 18, 2014.
Claims will be suspended in locations SMPET1-SMPET 7, and SMMPET, and released on 11.11.14.
||Some claims for Polysomnography and Sleep Studies were submitted with covered ICD-9 codes, in accordance with our Local Coverage Determination (LCD), but were denied incorrectly.
Due to an issue with the FISS mass adjustment process, the adjustments for the Sleep Studies have not been completed as anticipated. CGS is expecting a correction to the process and will have the adjustments completed by mid-October.
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 that 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 Studies 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, U5451, U5452, U5453, U5454
||Some outpatient therapy claims are receiving various RTPs/rejections incorrectly from the Common Working File (CWF) related to the functional therapy reporting requirements.
CMS made additional system modifications for U5452 to assist in the reduction of the number of THFR claim rejections. As a reminder, providers should review MLN Matters article SE1307 to verify that they have billed correctly. Providers may F9 and/or resubmit the claim after they have ensured the claim was billed correctly.
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.