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Claims Processing Issues LogClaims 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

07.09.2018

Open

Part A Providers

Providers are unable to access eligibility information via the FISS Direct Data Entry (DDE) screen Option 10, Beneficiary/CWF.

NA

NA

 

Updates

 

MAC Action

07.09.2018 – A resolution to this issue is tentatively scheduled for August 6, 2018.

Provider Action

07.09.2018 – Providers may use the IVR, ELGA, or myCGS to access Medicare eligibility information.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

07.02.2018

Open

All myCGS Users

myCGS portal Greenmail letters have not been delivered

NA

NA

 

Updates

07.03.2018 – On Monday, July 2nd, it was discovered that providers who are opted in for myCGS Greenmail did not receive letters in the portal beginning June 19th through June 29th. Impacted letters were sent via myCGS on July 2nd. Updated letters are also being generated to account for the delay and extend timeliness requirements. We will provide an update once these letters are available. We apologize for the inconvenience. Please note this only impacts providers who do not receive hard copy letters and are opted in to myCGS Greenmail.

MAC Action

07.02.2018 – CGS is researching the issue.

Provider Action

07.03.2018 – Please Note: This message only impacts providers who do not receive hard copy letters and are opted in to myCGS Greenmail.

07.02.2018 – No action at this time.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.11.2018

Open

Outpatient 13X type of bill

It has been brought to CGS' attention by CMS that Positron Emission Tomography (PET) claims containing certain radiopharmaceutical Healthcare Common Procedure Coding System (HCPCS) codes are returning to provider (RTP'ing) in error as of January 1, 2018, date of service (DOS).

Reason Code 32440
HCPCS Codes:
A9515, A9586, A9587, and A9588

NA

 
Updates

07.11.2018 – Refer to Provider Action below.

06.27.2018 – No update at this time.

MAC Action

06.11.2018 – There is a permanent fix in Change Request (CR) 10622 to be implemented in the October 2018 release.

Provider Action

06.11.2018 – If providers are aware of claims that RTP'd in error with reason code 32440, they may F9 the claim(s) or resubmit.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

06.04.2018

Open

Inpatient Prospective Payment System (IPPS) Providers

The Fiscal Intermediary Shared System (FISS) has determined that Inpatient claims with patient status codes 02 and 82 are being overpaid (overpayment of the Diagnosis Related Group (DRG).

NA

NA

 
Updates

06.27.2018 – No update at this time.

06.08.2018 – A correction is tentatively scheduled for July 23, 2018.

MAC Action  
Provider Action

NA

Proposed Resolution

06.04.2018 – Once FISS has determined a correction it will be implemented and CGS will initiate adjustments to collect against overpayments.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Open

Part A Providers

Claims submitted for processing with a Medicare Beneficiary Identifier (MBI) that were returned for valid reasons currently cannot be corrected through the Fiscal Intermediary Shared System (FISS) Direct Data Entry (DDE) system. The issue will be resolved no later than Tuesday, July 3, 2018.

NA

NA

 
Updates

07.11.2018 – Refer to Provider Action below.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

MAC Action  
Provider Action

05.22.2018 – To avoid delays in payment, submit a new claim to CGS if an MBI claim was returned to you.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.22.2018

Open

Part A Providers

The Fiscal Intermediary Standard System (FISS) has identified an issue with some Medicare Secondary Payment (MSP) claims.

U6803, U6816, U6817, U6818, U6819, U681D, U681E, U681L, 39074

Suspend in Location SM0628

 
Updates

06.22.2018 – A new correction has been implemented and will go into production on July 23, 2018.

06.08.2018 – No further update at this time.

05.23.2018 – Reason code 39074 has been added to the list of codes to suspend.

MAC Action

05.22.2018 – MSP claims hitting an identified reason code (Reason Codes) will be suspended and not Returned to Provider (RTP). The correction for this issue will be installed into production on July 2, 2018, and suspended claims will be released.

Provider Action

NA

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.17.2018

Open

SNF

Claims are being submitted with the new Medicare Beneficiary Identifier (MBI) and the Fiscal Intermediary Standard System (FISS) is attaching an invalid Health Insurance Claim Number (HICN) to the claim, causing the claim to go to the Return to Provider (RTP) file for various reasons.

38119

MBI

07.02.2018
Updates

07.02.2018 – The release was installed and affected claims have been released.

06.27.2018 – No further update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

05.17.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions to suspend skilled nursing facility (SNF) claims submitted with an MBI that receive reason codes 38119 until an update is installed. The update is currently scheduled for July 2, 2018. The affected claims will be suspended in status/location S MPMBI.

MAC Action

05.17.2018 – After the update, which is currently scheduled for July 2, 2018, is implemented, CGS will release the claims to continue processing.

Provider Action

05.17.2018 – No action required.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.14.2018

Open

Part A Outpatient 13X Type of Bill

Because of a known Fiscal Intermediary Standard System (FISS) issue, outpatient claims were recycling in the Common Working File (CWF) inappropriately. This issue was/is occurring because the allowed amounts associated with the Average Sales Price (ASP) drugs are not able to be included in with the EXP TO DED field.

E461J

Claims will be suspended in location SME461 until the system is corrected.

 
Updates

06.27.2018 – No update at this time.

05.22.2018 – No recurring updates will be provided on this since the implementation is October 1, 2018 and claims will be released at that time.

MAC Action

05.14.2018 – The correction for this issue will not be implemented until the October FISS release, which will be October 1, 2018. CGS will then release all affected claims to process.

Provider Action

NA

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.10.2018

Open

Part A Providers

Claims are RTPing stating that "The Health Insurance Claim (HIC) number is not found in the Common Working File (CWF) Crosswalk."

U5061

NA

06.27.2018

Updates

06.27.2018 – It has been determined that this is not an issue.

06.11.2018 – No update at this time.

05.22.2018 – No update at this time.

MAC Action

05.10.2018 – CGS is researching to determine if there is an issue.

Provider Action

05.10.2018 – Monitor J15 Part A Claims Processing Issues Log for updates.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.09.2018

Closed

Part A Claims

Claims that were originally submitted for processing with a Health Insurance Claim Number (HICN) as the beneficiary identifier are being incorrectly displayed in Direct Data Entry (DDE) with the Medicare Beneficiary Identifier (MBI). Claims should be displaying in DDE with the original identifier submitted on the claim (either the HICN or MBI).

NA

HICN/MBI

06.04.2018

Updates

06.06.2018 – A resolution to this issue was implemented on June 4, 2018.

05.22.2018 – No update at this time.

05.09.2018 – If you use the MBI returned through this display error on claims, the beneficiary will receive a Medicare Summary Notice with the MBI on it, possibly before they receive their new Medicare card containing their MBI. This issue will be resolved no later than May 29, 2018.
For More Information

MAC Action

No action at this time.

Provider Action

05.09.2018 – To avoid confusion, please do not use a beneficiary's MBI until one of these occur:

  • They present their new Medicare card (which will contain their MBI)
  • The MBI is available through your Medicare Administrative Contractor's secure portal
  • Their MBI is shared through the remittance advice starting in October 2018
Proposed Resolution

05.07.2018 – This issue will be resolved no later than May 29, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.07.2018

Open

Outpatient Hospital (13X type of bill)

The Office of Inspector General (OIG) determined that Medicare payments were made inappropriately - Payment for Outpatient Services Provided to Beneficiaries Who Are Inpatients of Other Facilities.

NA

NA

06.30.2018
Updates

06.30.2018 – Adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

MAC Action

05.07.2018 – CMS has instructed Medicare Administrative Contractors (MACs) to adjust claims that were inappropriately paid within dates January 1, 2013 through March 31, 2017. Claims can be identified as XXK type of bill and the 'Remarks' page of the claim(s) will indicate "A-09-16-02026". Adjustments are to be completed by June 20, 2018.

Provider Action

05.07.2018 – Providers must refund all improperly collected deductible and/or coinsurance amounts to the beneficiaries. Reference material in article linked above in Description of Issue, i.e., SE17033.

Proposed Resolution

NA

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

05.01.2018

Open

Inpatient Prospective Payment System Claims (IPPS)

With the implementation of Change Request 10145, certain IPPS claims with Patient Status Code 07 are not processing correctly.

NA

Patient Status Code 07

06.30.2018
Updates

06.30.2018 – Mass adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – No update at this time.

MAC Action

05.01.2018 – CGS will mass adjust impacted claims by June 22, 2018. Impacted claims will have receipt date of on or after 01.02.2018 through 04.23.2018, which is the date the correction was implemented.

Provider Action

NA

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.25.2018

Open

Skilled Nursing Facility (SNF) Providers

During the installation of the January 2018 release, the CWF Host did not synchronize a CWF table necessary to include updates for Change Request 10262, 2018 Annual Update of HCPCS Codes for SNF CB Update. As a result, a number of SNF claims were rejected in error.

C7252

HCPCS codes A9606, C9741, J9022, J9023, J9034, J9203, J9285 or J9301.

06.30.2018
Updates

06.30.2018 – Mass adjustments have been completed.

06.27.2018 – No update at this time.

06.08.2018 – No further update at this time.

05.22.2018 – Adjustments for claims rejected in error will be completed by June 25, 2018.

MAC Action

04.25.2018 – CGS will mass adjust impacted claims within 60 calendar days.

Provider Action

NA

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.19.2018

Open

Providers who submit claims for Molecular Diagnostic (MolDX) testing

Upon retiring the MolDX BioFire Gastrointestinal (GI) Panel, there is question as to whether the test, billed with CPT codes 87507 or 87999, is, in fact, a part of MolDX.

NA

MolDX CPT codes 87507 and 87999

06.22.2018

Updates

06.22.2018 – Adjustments for claims with this issue have been completed.

06.08.2018 – No update at this time.

05.22.2018 – Part A affected claims have been identified, but there is no definitive date as to when the claim will be adjusted.

MAC Action

CGS is currently analyzing data back to 01.01.2017 to determine validity and our next steps.

Provider Action

No action required for providers.

Proposed Resolution

TBD

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

04.09.2018

Open

Outpatient

Providers are receiving denials stating that no MolDX Z-ID was listed on the claim or the MolDX Z-ID and HCPCS associated is a mismatch.

5D605

All MolDX codes

 
Updates

07.11.2018 – No update at this time.

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

05.22.2018 – No updates at this time.

04.23.2018 – No update at this time.

MAC Action

04.09.2018 – CGS has determined that some providers have submitted requests through the DEX Diagnostics Exchange, which will provide a Z identifier that is related to the test submitted along with the documentation submitted to support how the test is performed. Providers are billing claims with the MolDX Z-ID before the documentation is reviewed by the MolDX team and prior to letter being sent to the provider giving the outcome of their registration. Research has also shown that the Z-ID being submitted with a HCPCS code is not the one that is associated with Z-ID on file.

Provider Action

04.09.2018 – Providers who have received denial 5D605 should verify against the letter sent to you from the MolDX team that you are using the correct code associated with MolDX Z-ID on the claim. Providers who have recently registered for a MolDX Z-ID for a test and have not received a letter from the MolDX team letting them know the outcome of the registration may submit claims; however, the line for that test will be denied until the MolDX team has finished the review or claims will be held until the registration process has been completed. Providers who have registered a test through DEX exchange and received a Z-identifier, but have not uploaded the supporting documentation for the MolDX team to receive and review should submit the needed documentation to complete the process.

Reference: CGS-MolDX Test Registration (CM00003)

Claims that have denied with reason code 5D605 should be submitted as redetermination requests.

Proposed Resolution  

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

03.29.2018

Open

All Part A Providers

The Fiscal Intermediary Standard System (FISS) rejected Non-Group Health Plan (GHP) (No-Fault, Worker's Comp, and Liability) claims processed on or after October 3, 2016, incorrectly.

34133, 34134, 34137, 34138, 34139, 34140, 34141, 34142, 34143, 34144, 34145, 34146, 34147, 34148, 34149, 34152, 34153, 34154, 34299, 34300, 34304, 34379, 34381, 34383, 34507, 34508, 34512, 34544, 34545 or 34549

No-Fault, Worker's Comp, and Liability

 
Updates

06.27.2018 – No update at this time.

06.08.2018 – No update at this time.

05.22.2018 – No update at this time.

04.23.2018 – CGS will not adjust the incorrectly rejected claims until further direction is received from the Centers for Medicare and Medicaid Services (CMS).

03.30.2018 – FISS will install a fix on April 23, 2018 and claims rejected incorrectly shall be adjusted.

MAC Action

04.23.2018 – Adjustments have been put on hold until further direction.

03.30.2018 – The Centers for Medicare & Medicaid Services (CMS) has provided instructions for CGS to mass adjust claims rejected with the above listed reason codes once the fix has been installed.

Provider Action

NA

Proposed Resolution

03.30.2018 – FISS will install a fix on April 23, 2018.

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Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved

11.21.2017

Open

Claims for Qualified Medicare Beneficiaries (QMB)

Payers secondary to Medicare aren't able to process some of your direct billed claims due to patient responsibility deductible and coinsurance amounts on the Medicare Remittance Advice (RA) showing zero. Claims automatically crossed over from Medicare to secondary payers aren't impacted.

NA

NA

06.08.2018

Updates

06.08.2018 – Adjustments have been completed.

05.22.2018 – Claims are currently being adjusted and the adjustments will be completed by May 25, 2018.

03.16.2018 – Per CR 10494, dated March 16, 2018, CGS will initiate adjustments for QMB claims with a date of receipt prior to 12.08.17. The adjustment is to produce "replacement" remittance advices (RAs) that providers can submit to supplemental payers to coordinate benefits as necessary.

02.09.2018 – CMS issued Change Request 10433 and MM10433 which will reintroduce Qualified Medicare Beneficiary (QMB) information in the Medicare Remittance Advice (RA) and Medicare Summary Notice (MSN). CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

01.17.2018 – As indicated in the revised SE1128 article, CMS systems reverted back to the previous display of patient responsibility for QMBs on the Medicare RA.

01.09.2018 – No additional update at this time.

01.03.2018 – Reference SE1128 for additional information.

12.05.2017 – No additional update at this time.

MAC Action

03.16.2018 – CGS will complete the adjustments within a 180 day timeframe.

Provider Action

03.16.2018 – Monitor remittance advices for QMB beneficiaries for dates of receipt prior to 12.08.17.

11.21.2017 – Providers may want to hold QMB claims and submit them after December 8. Reference the CMS QMB Remittance Advice Issue announcement for additional information.

Proposed Resolution

03.16.2018 – MACs to adjust identified claims as directed.

02.09.2018 – CR 10433 is effective July 1, 2018, for claims processed on or after July 2, 2018.

11.21.2017 – On December 8, 2017, CMS systems will revert back to the previous display of patient responsibility for QMBs on the Medicare RA.

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