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Claim Payment Alerts
Updated: 04.02.2025
Please reference this page for information about confirmed, system-related issues before you reach out to Customer Service. Click on the description to view details and check back often for updates that we post when they become available.
Closed issues remain on the active log for approximately 60 days before they move to the resolved issues archive list at the bottom of the page.
If you still have questions, please contact Customer Service or use one of our self-service tools.
Date Reported |
Description |
03.11.2025 |
This issue affects home health (HH) claims for patients that have been on HH for 37 or more consecutive periods in a single admission. The Common Working File (CWF) can only hold the 36 most recent periods of care on HHEH for any beneficiary. Periods that precede the most recent 36 will be dropped off the file and are not retrievable online. When the admission period drops from CWF (also drops from the beneficiary's eligibility record), claims for periods 37 and later cannot find the admission period and the claim is returned to provider (RTP) with reason code U537I "The FROM and THROUGH dates on the HH claim fall outside of an HH Admission period for the same provider." |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open: This issue is in research. |
Home Health |
Some Claims Editing for Reason Code U537I, Home Health (HH) Claim Falls Outside of an HH Admission Period for the Same Provider |
N/A |
|
MAC Action |
|
Provider Action |
No provider actions are needed currently. We will provide an update as soon as it is available. |
Proposed Resolution |
|
|
11.14.2024 |
Reason Codes 17729 & 17730: Hospice certifying physician edits applied to claims without occurrence code 27 in error. Please see the billing guidance for claim submission errors below. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Hospice |
17729 & 17730 |
N/A |
11.18.2024 |
MAC Action |
|
Provider Action |
CR13531 implemented additional edits for hospice certifying physician Medicare enrollment on October 7 and November 18, 2024.
Please follow the billing instructions below.
Claim Physician Billing Information
- Prior to November 18, 2024: For admission claim submissions (occurrence code 27 certification date matches the admission and "from" dates), report the following in the attending field:
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- Enter a physician's name and NPI only. Don't enter a nurse practitioner (NP) or physician assistant (PA).
- On or after November 18, 2024: For admission claim submissions (occurrence code 27 certification date matches the admission and "from" dates), report the following in the attending field:
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- Enter an independent physician, hospice physician, NP or PA.
- For all non-admission claim submissions (admission and "from" dates don't match), regardless of submission date:
- Attending Physician Field
- Enter the name and NPI of the attending physician designated by the patient.
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- The patient's designated attending physician could be an independent physician, hospice physician, NP or PA.
- Referring Provider Field
- Enter the name and NPI of the hospice's physician responsible for certifying patient's terminal illness.
- When no attending is designated, or the attending physician is also the certifying physician, only populate the attending physician field.
|
Proposed Resolution |
See Provider Action. |
|
07.03.2024 |
Reason Codes 326XX: One or more payer only codes may assign to a claim and cause it to return to provider (RTP) in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health & Hospice |
326XX |
Payer only code(s) |
|
MAC Action |
CGS removed value code Z9 from RTP claims submitted prior to, or during the installation of, the July 2024 release on 7.1.2024. |
Provider Action |
Remove any payer only codes before you F9/resubmit RTP claims or submit an adjustment or cancel claim.
Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1, section 190 for a complete list of payer only codes. |
Proposed Resolution |
A system fix is scheduled with the April 2025 release. |
|
08.01.2023 |
Reason Code 19963: Some home health claims returned to provider (RTP'd) in error because the corresponding NOA is offline. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
19963 |
NOA in Status/Location (S/LOC) O B9997 |
|
MAC Action |
3.27.2025 Update – Some HH claims with admission dates prior to August 23, 2023, and service "Through" dates approximately within 18 to 24 months of the admission date continue to edit for 19963 in error.
This issue should not impact HH claims with admission dates after August 23, 2023, or claims with "Through" dates more than 24 months from the admission date.
02.22.2024 – CGS was not able to restore/process all affected NOAs/claims. See Provider Action update below.
10.06.2023 – CGS will restore the affected NOAs and process the associated claims within 45 calendar days.
08.23.2023 – A system update will not allow additional NOAs to move offline. |
Provider Action |
3.27.2025 Provider Action – Change Request 13684, Revisions to Home Health Edit Matching Claims to Notices of Admission, was implemented on January 6, 2025. This corrected an issue with admission dates that are 24 months aged and within the claim’s "From" and "Through" dates from editing for 19963. If an HHA has claim that meets these criteria and it was processed before the January 6, 2025, fix, please return it for processing.
HHAs still need to ensure if reason code 19963 did edit correctly and if applicable, take appropriate action. See the February 21, 2024, provider action for more information.
01.06.2025 – Continue to monitor RTP claims and correct the NOA and/or claim when:
- There's no NOA on file for the admission.
- The NOA RTP'd or rejected.
- The HHA cancelled and never resubmitted the NOA.
- The claim admission date and NOA "From" date don't match.
- Another claim with earlier service date(s) closed the admission.
02.22.2024 – If you identify NOAs/claims that CGS was not able to restore/process per the MAC Action on 10.06.2023, please fax your list of claims to 615-660-5982.
Review claims that RTP with RC 19963. If a claim doesn't meet the criteria above, correct and resubmit it. |
Proposed Resolution |
See MAC Action and Provider Action.
Update: A system fix is scheduled for the January 2025 release.
01.06.2025 – CR13684 ensures home health claims submitted more than 24 months after the admission date don't RTP in error when the associated NOA is offline. |
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