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Check here for a status of EDI systems and a log of resolved EDI issues.

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
11.06.2017 Closed OP Hospital – 13X Type of Bill Claims were line level rejecting in error with reason code 5D301 instead of 5D601

53D01 – Claim Level

53164, 53166, 53167 – Line level
N/A 12.12.2017
Updates

12.12.2017 – Claims that were suspended have been reprocessed. Claims that denied prior to suspension of claims have been adjusted.

11.06.2017 – It has been determined that claims that Line level rejected with reason codes 53164, 53166, and 53167 were Claim level rejected with reason code 53D01 (MD must be readily available) in error. Reason code 5D601 (Not medically necessary based on information received) is the correct Claim level reason code for the three Line level reason codes.

MAC Action

12.12.2017 – See Updates

CGS has corrected the claim level reason code from 5D301 to 5D601. Claims that Line level denied (Status Location DB9997) with reason codes 53164, 53166, or 53167 should now deny at the claim level with the appropriate reason code (5D601).

CGS is still researching to determine if there is an issue with the Line level denial reason codes.

Provider Action

12.12.2017 – Providers should monitor their remittance advice(s) to verify claims have processed.

11.06.2017 – Monitor the Claims Processing Issue Log (CPIL) for updates to the issue.

To determine the correct Line level reason code denial, providers should go to Page 02 in Direct Data Entry (DDE), and F11 three times to MAP171D. The appropriate line level reason code will be displayed in the MED REV RSNS field on the affected claim line.

Proposed Resolution

See Provider Action


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