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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
11.13.2017 Open Home Health Negative Pressure Wound Therapy (NPWT) claims billed on a 34X Type of Bill (TOB) are going to the Return to Provider (RTP) incorrectly with reason code 38054. 38054 NPWT Billing Elements  
Updates

11.13.2017 – The Fiscal Intermediary Standard System (FISS) is looking at the 34X as a duplicate to the 329 TOB, causing the reason code 38054 to apply.

MAC Action

11.13.2017 – CGS will update the internal edit to suspend NPWT claims to status/location S M3805.  If the claim shows NPWT in the REMARKS field (FISS Page 04), CGS will release the claim to continue processing.  If the REMARKS field does not include NPWT, CGS will send the claim to RTP.

Provider Action

11.13.2017 – When billing NPWT claims (34X TOB), enter NPWT in the Remarks field.  If your claim goes to the RTP file (T B 9997), enter NPWT in the Remarks field (FISS Page 04), and press F9.

Proposed Resolution

11.13.2017 – See Provider Action above.



Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
11.13.2017 Open Hospice Billing transactions submitted with reopening Type of Bill (TOB) 8XQ are receiving reason code 31411 indicating the occurrence span code 77 is not valid.  31411 Occurrence Span Code 77  
Updates

11.13.2017 – It has been determined that reason code 31411 was not updated to recognize the reopening TOB (XXQ) as a valid TOB. All billing transactions receiving reason code 31411 with a reopening TOB will be suspended in status/location S M3141. A resolution has been developed; however, it has not been scheduled for implementation.

MAC Action

11.13.2017 – No action at this time.

Provider Action

11.13.2017 – No action at this time.

Proposed Resolution

11.13.2017 – A resolution has been developed; however, it has not been scheduled for implementation.  All billing transactions receiving reason code 31411 with a reopening TOB will be suspended in status/location S M3141.



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

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

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

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

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
08.21.2017 Closed Home Health Home health no-payment claims submitted with condition code 21 are being denied in error with an incorrect reason code (37253 - no OASIS assessment found). No payment claims do not require an OASIS assessment. 37523 Condition Code 21 09.26.2017
Updates

09.26.2017 – Research revealed that no-payment claims submitted with a 329 type of bill (TOB) will generate an incorrect denial reason code. No-payment claims must be submitted with TOB 320 and condition code 21. For details on submitting no-payment claims, refer to the CGS Home Health No-Payment Billing (Condition Code 21) Web page.

08.21.2017 – The Fiscal Intermediary Standard System (FISS) and the Centers for Medicare & Medicaid Services (CMS) are aware of this issue and are currently working on a resolution.

MAC Action

NA

Provider Action

Bill no-payment claims with the appropriate Type of Bill 320 and condition code 21 to prevent an incorrect denial.

Proposed Resolution

NA



Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
08.21.2017 Pending Home Health and Hospice Home health and hospice claims and Requests for Anticipated Payment (RAPs) are being rejected in error. U6815, U6816, U6817, U6818 NA  
Updates

11.20.2017 - CGS has initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the system release, which was implemented November 6, 2017.

11.13.2017 – The system release, which was scheduled for November 6, 2017, was implemented. CGS will initiate adjustments to the claims that were rejected in error. Please note the Provider Action below.

10.30.2017 – No additional update at this time.

10.09.2017 – See the MAC Action and Provider Action sections below.

09.22.2017 – In addition to claims being rejected in error, Requests for Anticipated Payment (RAPs) were also being rejected in error with reason codes U6815, U6816, U6817, or U6818. CMS has provided instructions for CGS to cancel all the RAPs that were rejected in error between 6/5/17 through 8/7/17.

Once the RAPs have cancelled, CGS will notify providers to resubmit the RAPS.

In addition, within 45 days after the 11/6/17 system release, CGS will initiate claim adjustments that were rejected in error during this time period.

08.21.2017 – The Fiscal Intermediary Standard System (FISS) is aware of this issue and are currently working on a resolution.

MAC Action

11.20.2017 - CGS has initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the system release, which was implemented November 6, 2017.

10.09.2017 – CGS has initiated cancels for all the home health Requests for Anticipated Payment (RAPs) that were rejected in error between 6/5/17 through 8/7/17.

Provider Action

10.09.2017 – Providers need to monitor their remittance advice for the cancelled RAPs that were originally rejected with reason codes U6815, U6816, U6817, or U6818. Once they appear on your RA, please resubmit the RAP to process correctly.

Proposed Resolution

10.09.2017 – A system release is scheduled for November 6, 2017, at which time, CGS will initiate adjustments to the claims that were rejected in error. The adjustments will be completed within 45 days after the November system release is implemented.



Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
05.06.2016 Pending Hospice An issue has been identified with the 60 day 'high' and 'low' Routine Home Care rate being applied incorrectly with dates of service on or after January 1, 2016. NA NA  
Updates

11.13.2017 – No additional update at this time.

10.30.2017 – No additional update at this time.

09.28.2017 – Refer to the MAC Action and the Provider Action section below.

05.30.2017 – Refer to the Provider Action section below.

09.28.2016 – In the August 18, 2016, Provider eNewsExternal PDF CMS notified hospices that Medicare Administrative Contractors (MACs) would adjust claims to correct miscounting of routine home care days. Due to incorrect payments, MACs will stop adjustments until a solution is implemented.

09.16.2016 – Refer to the following articles for additional information:

05.06.2016 – The Centers for Medicare & Medicaid Services (CMS) is aware of, and is researching this issue.

MAC Action

09.28.2017-CGS will initiate the adjustments over the three months following the submission of all lists, concluding the process by January 29, 2018.

Provider Action

09.28.2017 – The Centers for Medicare & Medicaid Services (CMS) issued the MLN Matters® article SE17029, "Process for Hospices to Submit a List of Cliam Requiring Adjustments"External PDF instructing hospice providers to submit a list of claims to be adjusted due to routine home care (RHC) and service intensity add-on (SIA) payment errors. Hospice providers should submit their list of claims to CGS, no later than October 20, 2017, to CGS.MEDICARE.HHH.CLAIMS@cgsadmin.com.

The list of claim information should include only the following:

  • the document control numbers (DCNs) of the claims to be adjusted
  • the dates of service for each claim, and
  • whether the error is related to RHC days or SIA amounts.

DO NOT include personal health information, such as the beneficiary name, and health insurance claim number (HICN).

DO NOT submit a secured email. When your list of claims to be submitted is sent in a secured email, CGS is unable to access the list. Therefore, if you have submitted a secured email, please resend, unsecured.

05.30.2017 – Medicare has corrected most of the system errors associated with 2016 hospice service intensity add-on and RHC payments; however, two issues still remain, which require Hospices to submit adjustments. Refer to the MLN Matters Special Edition article SE17014External PDF for additional information.

Proposed Resolution

09.28.2017 – Refer to the MAC Action and the Provider Action section below.



Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
03.02.2016 Pending 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" web page for details.
E0419, V8029, V8030, V8031, and E46#V NA  
Updates

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


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