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J15 Part A Claims Processing Issues Log

Updated: 12.08.14

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

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 were denied incorrectly.

All affected claims should have been adjusted. If you locate claims that weren’t adjusted, you may adjust them and they should process correctly.

All affected claims have been adjusted.

Unfortunately, CGS is still having issues with adjusting claims for sleep studies that were denied in error. Providers do have the option of submitting Redetermination requests for any claims you believe were denied in error for this reason. If you are submitting a Redetermination request past the timeframe for filing a first-level appeal (i.e., more than 120 days from the date of the initial determination), we strongly recommend you provide supporting documentation for “late filing” with your request and reference the CGS Claims Processing Issues Log. As a reminder: registered users can file electronic Redetermination requests through our secure web portal, myCGS. You may also complete the redetermination formPDF by electronically completing each field, then print the form, sign it, attach supporting documentation, and mail it.

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 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, 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.

All outpatient therapy claim issues should be resolved.

Issue is expected to be fully resolved 11.10.14.

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 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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