License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Ordering/Referring Provider Denial Job Aid

If you have received a claim rejection/denial due to a missing/incomplete/invalid ordering provider name and/or NPI, you must correct and resubmit your claim in order for payment to be considered. Use the following chart for guidance on correcting your claim.

ANSI Reason Code

ANSI Remark Code

ANSI Definition

What to Do

183

N574

The referring provider is not eligible to refer the service billed.

Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer.

Please verify that the claim ordering/referring provider information is accurate or contact the ordering/referring provider.

NOTE:

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Your supplier number is not eligible to provide this item.

The ordering/referring physician listed on the claim is not eligible to prescribe Power Mobility Devices (PMDs) based on his/her physician specialty, as listed in PECOS.

Step 1: If you submitted the ordering/referring physician information incorrectly, correct the information, and resubmit a new claim.

REFERENCE: MLN Matters Article MM8239.

NOTE: CGS will not correct ordering/referring claim denials via telephone reopenings. If you wish to appeal your claim, you must submit a redetermination with the corrected information, and the Redeterminations department has up to 60 days to complete the request. While submitting a redetermination is an option, CGS recommends that you simply correct and submit a new initial claim.

Your supplier number is not eligible to provide this item.

Step 1: If the licensure information on file is incorrect, submit a “Change of Information” on the Medicare enrollment application (CMS-855S) form to the National Provider Enrollment (NPE) along with any applicable licenses and/or certifications.

Step 2: Once your licensure information has been updated with the NPE, resubmit a new initial claim

NOTE:

Redeterminations: If you disagree with the claim decision, submit a redetermination request.

NOTE: CGS will not correct ordering/referring claim denials via telephone reopenings. If you disagree with the claim decision, submit a redetermination.

N265
N276
MA13

Claim/service lacks information which is needed for adjudication.

Missing/incomplete/invalid ordering provider primary identifier.

Missing/incomplete/invalid other payer referring provider identifier. Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

The ordering/referring provider NPI was either missing from the claim, is not found on the ordering/referring physician file, or has been terminated.

Step 1: Obtain the correct NPI for the ordering/referring provider information. Be sure to enter the name and NPI exactly as it appears in the PECOS records.

Step 2: Use the DME myCGS web portal to check the status of a claim denial for ordering/referring physician edits.

Step 3: Once you have obtained the correct name and NPI, submit a new initial claim. Be sure to enter the name and NPI exactly as it appears in the PECOS records.

N264
N575
MA13

Claim/service lacks information which is needed for adjudication.

Missing/incomplete/invalid ordering provider name.

Mismatch between the submitted ordering/referring provider name and the ordering/referring provider name stored in our records. Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.

The ordering/referring provider's name does not match the NPI.

Step 1: Verify the ordering/referring provider name and NPI are correct using myCGS, the Jurisdiction C IVR, or the NPI Registry.

Step 2: What suppliers can do to check the status of a claim denial for ordering/referring physician edits:

Use myCGS online web portal. myCGS will provide you with an explanation of the denial.

Step 3: Once you have obtained the correct name and NPI, resubmit a new initial claim. Be sure to enter the name and NPI exactly as it appears in the PECOS records.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Ordering/Referring Provider Denial Job Aid

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