Checking Claim Status FAQs

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1. Do you publish information on the status of suspended claims that have processing issues with the Fiscal Intermediary Standard System (FISS)?

   • The Fiscal Intermediary Standard System Claims Processing Issues Web page is available for providers to check the status of known or reported home health and hospice claims processing issues, including claims in a suspended status/location (S BXXXX or S MXXXX). Home health and hospice agency staff should refer to this web page before calling the Provider Contact Center with questions.

     Reviewed: 03.20.17

2. In some cases, why does it take more than 14 days to process my electronic Medicare claims?

   • The earliest an A/B Medicare Administrative Contractor (MAC) is able to pay "clean claims" (those needing no intervention or investigation by the MAC, or correction by the provider) submitted electronically is 14 days after the received date of the claim. Per the Medicare Claims Processing Manual (Pub. 100-04, Ch. 1, § 80.2.1.1), MACs, like CGS, have 30 days to process clean claims. While the typical timeframe to process claims is less than this, MACs have the full 30 days from the receipt date of a clean claim to process it. For this reason, providers should not expect that every clean claim submitted to their MAC will be paid on the 14th day after it is received. Claims not processed within the 30-day timeframe may be paid with interest.

     Home health providers should be aware that Requests for Anticipated Payment (RAPs) are not considered home health claims. Therefore, there is no specified timeframe for when RAPs must be processed by MACs, nor are RAPs subject to claims processing timeliness standards. In addition, RAPs are not eligible for interest payments when a processing delay occurs (Pub. 100-04, Ch 10, § 10.1.12).

     Reviewed: 03.20.17

3. My claims are suspended ("S" status code), but have reason code F5052 assigned to them. What causes this?

   • The Fiscal Intermediary Standard System (FISS) assigns reason code F5052 to claims when the Common Working File (CWF) is unable to locate the beneficiary's Health Insurance Claim Number (HICN) as it was submitted on the Medicare billing transaction. The most common reasons why providers receive this reason code include:

     • the HICN has not been previously processed by this office and the system is attempting to locate it at another CWF host site;
     • the HICN is in the process of being updated or changed; OR
     • the HICN submitted on the claim is not valid.

     If your claim is suspended (FISS S/LOC S BXXXX or S MXXXX) while the system is attempting to access the HICN at another CWF host site, please be aware that this process takes time. Once the beneficiary's HICN has been located at the host site, a "link" is created and the system will be able to process future claims you submit for this beneficiary more quickly. Additional information on suspended claims can be accessed in Chapter One – FISS Overviewof the Fiscal Intermediary Standard System (FISS) Guide.

     To avoid billing errors for invalid or changed HICNs, providers are encouraged to authenticate the beneficiary's HICN by reviewing the "CN" and "CORRECT CN" fields found on page 1 of ELGA or ELGH, prior to submitting billing transactions to Medicare. Information about accessing and reading these screens can be found in Chapter Two – Checking Beneficiary Eligibilityof the Fiscal Intermediary Standard System (FISS) Guide. Please note that provider access to ELGA/ELGH will be terminatedin the future. See Medicare Learning Network (MLN) Matters® article, SE1249for more information.

     HICNs can also be verified by using the myCGS® web portal or HIPAA Eligibility Transaction System (HETS). Access the myCGS User Manual web page and the HETS 270/271 Companion Guidefor more information.

     If your claim is rejected (FISS S/LOC R B9997) for an incorrect HICN, you will need to submit the corrected HICN on a new claim. If your claim is in the Return to Provider (RTP) file, - S/LOC T B9997 - you can correct the HICN by entering the correct HICN in the "PROCESS NEW HIC" field on FISS Page 01. Detailed instructions for using this field can be found in Chapter Five – Claims Correctionof the Fiscal Intermediary Standard System (FISS) Guide.

     Reviewed: 03.20.17

4. I have claims in FISS status/location S B90F0, as well as other suspended status/locations. What can I do to get these claims to process?

   • Claims in this status/location are suspended while they are comparing the information submitted on them to the beneficiary's information posted to the Common Working File (CWF) and can remain suspended for 6 to 7 business days. No provider intervention is required for claims in this status/location. A listing of common suspended status/location codes can be found in Chapter One – FISS Overviewof the Fiscal Intermediary Standard System (FISS) Guide.

     Reviewed: 03.20.17

5. What's the difference between a claim in RTP (T B9997), a claim that rejected (R B9997) and a denied claim (D B9997)?

   • Billing transactions that have been returned to provider (RTP) for correction (T B9997) are those that have missing, invalid, or incorrect information detected by the Fiscal Intermediary Standard System (FISS) or Common Working File (CWF) edits. Providers may correct these claims using the Claims CorrectionMenu Option 27 (home health) or 29 (hospice) in FISS. Rather than correcting the claim, providers may choose to submit a new billing transaction with the correct information when claims appear in T B9997. If a new billing transaction is submitted, CGS encourages providers to suppress the view of the claim in RTP.

     Billing transactions that reject (R B9997) do so because a duplicate billing transaction was received or the information on the billing transaction was not consistent with the beneficiary's eligibility file posted to CWF. If the error was due to duplicate billing, no provider action is needed. In order to receive Medicare payment, providers may need to submit an adjustment or resubmit the billing transaction after resolving the reason for the rejection.

     Claims that appear in D B9997 have been fully denied. This occurs when a claim is selected for Medical Review (MR) and no services are determined to be payable by Medicare, the claim was selected for MR and the medical documentation was not received timely, the provider submitted the claim as a demand denial, or the conditions for payment were not met by the billing provider. In most cases, if providers are disputing the denied charges, they must submit an appeal within 120 days of the denial date. When a claim is denied because the medical documentation was not received timely, (reason code 56900), a "56900 reopening" may be requested to have medical documentation reviewed by the Medical Review department. For more information, refer to the Reopenings web page on the CGS website.

     Additional information about FISS status/locations (S/LOC) is available in Chapter One – FISS Overviewof the Fiscal Intermediary Standard System (FISS) Guide.

     Reviewed: 03.20.17

6. What does it mean if my claim is in an "S" status code?

   • An "S" status code indicates that your claim is in a suspended status/location (S/LOC). Generally, providers do not need to take action for claims that are suspended, as all claims temporarily suspend in different S/LOC as they process through the Fiscal Intermediary Standard System (FISS).

     Reviewed: 03.20.17

7. Is provider action ever needed for suspended claims?

   • The only time provider action is needed for claims in a suspended S/LOC is when the claim encounters a medical review edit, which causes an Additional Development Request (ADR) to be generated. For more information on ADRs, see the Additional Development Request (ADR)quick resource tool. More information is also available in the Additional Development Request (ADR)/Medical Review FAQs web page.

     At times, suspended claims may require manual intervention by CGS staff to successfully process in FISS. Suspended claims are monitored, and worked in the order they are received. These claims can be identified with an "S" status code, followed by a location code beginning with "M", indicating "manual" intervention. With the exception of claims suspended for Medical Review (S M50MR) or suspended claims containing Medicare Secondary Payer (MSP) information (S MVC14, S MVC43, etc.), providers are encouraged to call CGS when their claims have been in an "S MXXXX" status/location (S/LOC) for longer than 30 days. Providers are encouraged to call with questions regarding MSP claims or claims in Medical Review that have been in the same "S MXXXX" S/LOC for longer than 60 days.

     Reviewed: 03.20.17

8. How can I tell if my claims have been received by CGS?

   • Providers with access to FISS don't need to call CGS Provider Contact Center (PCC) to determine the receipt of billing transactions. FISS Inquiry Option 12 (Claim Summary) can be used to identify if billing transactions were received or their current status in the Medicare claims processing sequence. Review Chapter Three – Inquiry Menuof the Fiscal Intermediary Standard System (FISS) Guide for instructions on using FISS Inquiry Option 12. Additional information about FISS status/location (S/LOC) codes is available in Chapter One – FISS Overviewof the Fiscal Intermediary Standard System (FISS) Guide.

     The CGS Interactive Voice Response (IVR) unit can also be accessed to determine whether Medicare claims have been received into FISS. To access the IVR, call (877) 220-6289. Instructions for using the IVR are available here. The myCGS® web portaL can also be used to check the status of Medicare claims submitted to CGS. Access the myCGS User Manual for more information.

     Reviewed: 03.20.17