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Check here for a status of EDI systems and a log of resolved EDI issues.

Claims Processing Issues Log

Listed below are current system-related claims processing issues. Updates are made to this log frequently, as soon as information becomes available. We encourage you to review this log often and prior to contacting the Provider Contact Center. A list of resolved issues is also available at the end of this list. If you still have questions, please contact the Provider Contact Center or use one of our self-service tools.

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

02.20.2018

Open

Home Health and Hospice

The MAS system, used to effectuate favorable and partially favorable Appeals, is not working appropriately to allow some claims to process and pay.

NA

Appeal Redeterminations

 

Updates

 

MAC Action

02.20.2018 – This issue has been reported to the Centers for Medicare & Medicaid Services (CMS) MAS contractor.

Provider Action

02.20.2018 – CGS is unable to identify the claims affected by this issue.  Therefore, if you have received a partially or fully favorable appeal decision within the last 60 days, and have not yet received payment, please contact the CGS Provider Contact Center at 1.877.299.4500, Option 1.

Proposed Resolution

 


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.18.2018

Open

Hospice

CGS is aware that some adjustments continue to pay the incorrect 60 day 'high' and 'low' Routine Home Care rate

NA

NA

 02/19/2018

Updates

02.19.2018 – The previously adjusted claims have been readjusted; therefore, all claims payment should be correct.  If you still believe you received an incorrect payment, please review the claim and provide a detailed explanation before contacting the Provider Contact Center (PCC).

02.09.2018 – No additional update at this time.

01.26.2018 – After additional research, it has been determined why previous adjustments did not correct the payment as anticipated. CGS will gather the necessary data and will re-adjust the adjustments that were processed with the incorrect payment.

MAC Action

01.26.2018 – CGS is working to gather the necessary data and will re-adjust the adjustments that were processed with the incorrect payment.

01.18.2018 – CGS is researching this issue and waiting for direction from the Centers for Medicare & Medicaid Services (CMS).

Provider Action

01.26.2018 – No action is required by providers at this time.

01.18.2018 – No action is required by providers at this time.

Proposed Resolution

01.26.2018 – CGS will re-adjust the adjustments that were processed with the incorrect payment.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.11.2017

Open

Home Health

Type of bill 3XG PEP adjustments caused a negative amount in Value Code 17 which caused overpayments to display on the Summary page of the remittance advice in the Adjustment to Balance Field.

NA

NA

 
Updates

01.09.2018 – A resolution to this issue is scheduled for implementation on March 5, 2018.

12.11.2017 – The resolution was implemented on November 20, 2017. However, after checking a sample, it was found the issue was still happening. This has been reported to the Fiscal Intermediary Standard System (FISS) maintainer.

11.27.2017 – No additional update at this time.

11.13.2017 – A resolution to prevent this from happening is scheduled for implementation on November 20, 2017. Providers are unable to correct this issue by adjusting the claim

MAC Action

11.13.2017 – No action at this time.

Provider Action

11.13.2017 – Do not adjust the claim in an attempt to fix this issue. Further instructions will be forthcoming.

Proposed Resolution

01.09.2018 – A resolution to this issue is scheduled for implementation on March 5, 2018.

11.13.2017 – A resolution to prevent this from happening is scheduled for implementation on November 20, 2017.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

10.30.2017

Open

Home Health

The reason code 37253 cannot be bypassed for claims that are submitted with the 'DR' condition code (CC) indicating a waiver under §1135 of the Social Security Act.

37253

DR Condition Code

 
Updates

02.09.2018 – No additional update at this time. 

02.01.2018 – CMS issued MM10372External PDF "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" with information about creating a bypass with condition code DR is reported on the claim.

01.09.2018 – CMS released Change Request 10372 "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" on January 5, 2018, with an implementation date of July 2, 2018.

12.11.2017 – CMS is working to issue a Change Request to resolve this issue.

11.27.2017 – No additional update at this time.

11.13.2017 – No additional update at this time.

10.30.2017 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions to suspend home health claims after validating CC 'DR'. Periodically when a number of suspended HH claims build up, or not less frequently than weekly if any HH claims are suspended, the reason code 37253 will be temporarily deactivated. The suspended claims with CC 'DR' will be released for processing, and then the reason code will be reactivated.

MAC Action

10.30.2017 – This process will continue for as long as claims for dates of service subject to the waiver are timely or until the reason code can be revised.

Provider Action

10.30.2017 – None

Proposed Resolution

01.09.2018 – CMS released Change Request 10372 "Ensuring Correct Processing of Home Health Disaster Related Claims and Claims for Denial" on January 5, 2018, with an implementation date of July 2, 2018.

10.30.2017 – CMS will add a bypass for CC 'DR' to reason code 37253 in a future Change Request, so this workaround will not be needed in the case of future emergencies.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.02.2016

Open

Home Health

01.17.2017 (Home Health) – Some home health claims and adjustments are cycling in FISS in status/location S M90H4 with reason codes E0419, V8029, V8030, and V8031.
03.02.2016 – The issue involving some adjustments (type of bill XXG), continues as previously reported. Refer to the "Resolved Fiscal Intermediary Standard System (FISS) Issues"External PDF web page for details.

E0419, V8029, V8030, V8031, and E46#V

NA

 
Updates

02.06.2018 – A resolution related to reason codes V8030 and V8032 has been scheduled for implementation on March 5, 2018.

02.01.2018 – The CGS Claims department continues to work with the Technical staff. No additional update at this time.

01.09.2018 – No additional update at this time.

12.11.2017 – Although a resolution was implemented on November 6, 2017, claims continue to suspend. Additional research is being done.

11.27.2017 – A resolution was implemented on November 6, 2017 to correct reason code V8031.

11.13.2017 – No additional update at this time.

10.30.2017 – No additional update at this time.

08.01.2017 – Although the July 3, 2017 system release did allow some claims to process from the status/location S M90H1, an additional resolution is needed. At this time, the additional resolution has not been scheduled for release. Please note that CGS continues to explore manual workarounds to allow these claims to process.

05.30.2017 (Updated 06.09.2017) – At this time, adjustments (TOB XXG) continue to suspend in status/location S M90H4 and S M90H1. Additional issues related to the value codes were discovered. FISS maintainers have scheduled a resolution for implementation on July 3, 2017. Please note that this resolution does not address final claims.

12.01.2016 – A resolution to this issue has been scheduled for implementation in April 2017. Claims and adjustments affected by this issue will suspend in status/location S M90H4 with reason code E0419, V8029, V8030, and V8031.

05.06.2016 – The April 25, 2016 system implementation failed to fully resolve this issue. The system maintainer has been informed. As mentioned below, CGS will continue to manually work through the suspended adjustments.

03.02.2016 – A resolution to this issue is scheduled for implementation on April 25, 2016. Until a resolution is implemented, CGS will manually work through the suspended adjustments. Please note that due to the manual process and other limitations, some may not process until the scheduled implementation.

MAC Action

NA

Provider Action

NA

Proposed Resolution

NA


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.21.2017

Closed

Home Health and Hospice

Payers secondary to Medicare aren't able to process some of your direct billed claims due to patient responsibility deductible and coinsurance amounts on the Medicare Remittance Advice (RA) showing zero. Claims automatically crossed over from Medicare to secondary payers aren't impacted.

NA

NA

2.06.2018

Updates

02.09.2018 – CMS issued Change Request 10433 and MM10433External PDF which will reintroduce Qualified Medicare Beneficiary (QMB) information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN). CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

01.17.2018 – As indicated in the revised SE1128 article, CMS systems reverted back to the previous display of patient responsibility for QMBs on the Medicare RA.

01.09.2018 – No additional update at this time.

01.03.2018 – Reference SE112External PDF for additional information.

12.05.2017 – No additional update at this time.

MAC Action

NA

Provider Action

11.21.2017 – Providers may want to hold QMB claims and submit them after December 8. Reference the CMS QMB Remittance Advice IssueExternal PDF announcement for additional information.

Proposed Resolution

02.09.2018 – CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

11.21.2017 – On December 8, 2017, CMS systems will revert back to the previous display of patient responsibility for QMBs on the Medicare RA.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.03.2018

Closed

Hospice

When a hospice Notice of Election (NOE) is submitted via EDI, effective with CR 10064External PDF, the data included in the non-required Patient Status and Source fields is not being removed and is causing the NOE to suspend with reason code E2101.

E2101

Patient Status and Source fields

02.12.2018

Updates

02.12.2018 – A resolution was successfully implemented on February 5, 2018. Hospice providers may submit NOEs via EDI, or by using FISS DDE.

02.09.2018 – CGS technical staff are currently testing the implemented system release.

01.17.2018 – Claims are currently suspending in status/location S MHEAT. A process has been put in place to remove the date in the patient status and source fields, until the system release is implemented on February 5, 2018.

MAC Action

01.03.2018 – CGS is exploring options for a work around to allow NOEs to process.

Provider Action

01.03.2018 – CGS recommends that hospice providers submit NOEs using FISS direct data entry (DDE) until a fix to this issue is implemented.

Proposed Resolution

01.03.2018 – The FISS maintainer is aware of this issue. A fix to this issue is scheduled to be installed on February 5, 2018.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.03.2018

Closed

Hospice

The Companion Guide created by CMS included the use of the procedure code Q5009 (not otherwise specified code). This required a description in the service line (data element SV202-7); however, this information was not identified as being required in the Companion Guide. As a result, NOEs received without the procedure code description data element will reject in the EDI front-end editing and will be returned via the 277 Claims Acknowledgement Transaction.

NA

Procedure Code

02.12.2018

Updates

02.12.2018 – A resolution to other issues was successfully implemented on February 5, 2018. Hospice providers may submit NOEs via EDI, or by using FISS DDE.

02.09.2018 – No additional update at this time.

01.17.2018 – The Companion GuideExternal PDF has been updated showing the entry of NOE for the data element SV202-7. However, because issues still exist, hospice providers should submit NOEs using FISS direct data entry.

MAC Action

01.03.2018 – No action at this time.

Provider Action

01.03.2018 – CGS recommends that hospice providers submit NOEs using FISS direct data entry (DDE) until a fix to this issue is implemented.

Proposed Resolution

01.03.2018 – CMS is working to revise the Companion Guide requirements to include appropriate data element.


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

01.25.2018

Closed

All providers

The Interactive Voice Response (IVR) system is not calculating the QMB deductible and coinsurance amounts correctly.

NA

NA

02/12/2018

Updates

02.14.2018 – This issue has been resolved.

02.09.2018 – No additional update at this time.

MAC Action

01.25.2018 – CGS is working to resolve this issue.

Provider Action

02.14.2018 – Providers can now use the IVR (1.877.220.6289) to obtain a breakdown of the deductible and coinsurance amounts.

01.25.2018 – At this time, please contact the home health and hospice Provider Contact Center (PCC) at 1.877.299.4500 for assistance in getting a breakdown of the deductible and coinsurance amounts.

Proposed Resolution  

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