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Reason Code Search and Resolution

Disclaimer: This is not a complete list of reason codes.

The Reason Code Search and Resolution tool allows you to view a reason code description and determine how to prevent/resolve the edit. You may search by reason code or keyword. All records matching your search criteria will be returned for your review. You may also select "Show all Reason Codes" to view the complete list.

If the reason code you enter does not display here, you may access any reason code description in the Fiscal Intermediary Standard System (FISS) Direct Data Entry (DDE) Reason Codes Inquiry Menu (Option 17) . For additional information, please reference the FISS DDE User Manual.

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Reason Code 7CS21


Dates of service billed are within a beneficiary Medicare Advantage (MA) plan enrollment period; therefore, no Medicare payment can be made.


  • Review the information on the Medicare Advantage (MA) Plans – Claim Filing Tips When A Beneficiary Receiving Home Health Services Enrolls / Disenrolls Web page.
  • Upon admission for Medicare-covered services, review all insurance (including Medicare Part D) cards the beneficiary has and verify the information on the card is valid.
  • Upon admission and prior to billing CGS, verify whether an MA plan will impact the dates of service by checking the beneficiary's eligibility file. This information is available in the myCGS "Plan Coverage" tab. It can also be found on the "PLAN INFORMATION" screen found on ELGA Page 1 and/or ELGH page 5.

NOTE: In December 2012, CMS announced plans to discontinue the CWF Beneficiary eligibility transactions (MLN Matters Special Edition article SE1249External PDF). In that same article, CMS announced that the HIPAA Eligibility Transaction System (HETS) would be the single source for this data. If you currently use CWF queries (HIQA, HIQH, ELGA, and ELGH) to obtain Medicare eligibility information, you should begin using HETSExternal Website.

  • See the CGS Checking Beneficiary Eligibility Web page for more information about the systems available to providers to check Medicare beneficiary eligibility information.
  • Since MA plan election records are updated the first part of each month, providers whose dates of service span two consecutive months or extend beyond 30 calendar days are encouraged to check MA plan information for the beneficiary monthly.
  • Review the "Bill Code" field on the myCGS "Plan Coverage" tab or the OPT field on the ELGA page 1 and/or ELGA page 5 to determine where the claim needs to be sent for payment.
    • If the OPT code or bill code is a 'C', the MA plan is responsible for processing the claim.
      • According to the Medicare Claims Processing Manual, (CMS Pub. 100-04, Ch. 11, §30.4External PDF), "While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS." In addition, "…the duration of payment responsibility by fee-for-service contractors extends through the remainder of the month in which hospice is revoked by hospice beneficiaries. MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked."
    • If the OPT or bill code is a '1', services may be submitted to CGS for processing.
  • The myCGS "Plan Coverage" tab will display the MA Plan's name, identifier, and contact information. If using ELGA/ELGH or the plan name and contact information is not available in myCGS, access the MA Claims Processing ContactsExternal Website directory, which contains a list of all active Medicare contracts and their corresponding plan type.
  • If the MA plan election is posted to the beneficiary's eligibility file in error, the MA plan will need to correct this information. Providers should contact the MA plan directly to update the beneficiary's record.
    • Providers should be aware that until the beneficiary's eligibility file is updated, any claims submitted to CGS will be impacted by the incorrect MA plan information; therefore, providers should not submit Medicare claims until the MA plan information is corrected.
  • If the MA plan election was correctly posted to the beneficiary's file and impacts your dates of service, you must look to the MA plan for reimbursement of services. Do not submit billing transactions to CGS for payment, unless the eligibility file indicates the fee-for-service (FFS) contractor is responsible for processing the beneficiary's Medicare claims or there is a hospice election that impacts the MA plan enrollment period and your services are unrelated to the hospice election.

Updated: 01.28.20

Disclaimer: CGS' online tools and calculators are informational and educational tools only, designed to assist suppliers and providers in submitting claims correctly. CGS makes no guarantee that this resource will result in Medicare reimbursement for services provided. Although we've made every reasonable effort to provide effective resources, CGS is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information that these tools provide. CGS is not responsible for any human or mechanical errors or omissions.


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