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Claims Processing Issues Log
Please reference this page for confirmed system-related claims processing issues before you contact the Provider Contact Center. Click on the description of the issue to view detailed information and check back often for updates that are posted when they become available.
Closed issues remain on the active log for approximately 60 days before they're moved to the resolved issues archive list at the bottom of the page.
If you still have questions, please contact the Provider Contact Center or use one of our self-service tools.
Date Reported |
Description of Issue |
11.06.2023 |
Beginning on 10.02.2023, FISS did not retain the fractional units on Direct Data Entry (DDE) claims with ambulance mileage services. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Ambulance |
32226 |
DDE claims with TOB 13X or 85X and ambulance mileage services |
|
Updates |
|
MAC Action |
|
Provider Action |
|
Proposed Resolution |
A system correction is tentatively scheduled. We will provide updates when available. |
|
08.07.2023 |
Non-OPPS claims returned to provider (RTP'd) with reason code W7048 in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Non-OPPS claims |
W7048 |
Claims received on or after July 1, 2023 |
|
Updates |
|
MAC Action |
CGS will override reason code W7048 until the system update is implemented in January 2024. |
Provider Action |
You may F9/resubmit claims that RTP'd in error. |
Proposed Resolution |
A system update is scheduled with the January 2024 release. |
|
07.03.2023 |
Some claims for audiologists who furnished certain diagnostic tests without a physician order returned to provider (RTP'd) in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Various Outpatient TOBs |
34963 |
Claims received on or after April 1, 2023, with modifier AB on all lines |
|
Updates |
|
MAC Action |
When all lines on the claim contain modifier AB, CGS will override reason code 34963 until the system update is implemented in January 2024. |
Provider Action |
Review claims that received reason code 34963.
- If modifier AB is reported on all claim lines, F9/resubmit the claim.
- If the claim also includes codes/lines without modifier AB, report the attending provider's name and NPI.
- If modifier AB is not reported on any claim lines, determine if it's appropriate to report modifier AB and/or the attending provider's name and NPI.
NOTE: An audiologist is not a valid attending provider. Please reference the CMS MLN Matters articles MM12289 (reason code 34963) and MM13055 (modifier AB) for additional information. |
Proposed Resolution |
A system update is scheduled with the January 2024 quarterly release. |
|
06.29.2023 |
Due to a coding error, certain beneficiary records in the Common Working File (CWF) reflected an incorrect initial date of first dialysis (e.g., ESRD eligibility date or first of the month when the date of first dialysis occurred after the eligibility date). As a result, the onset payment adjustment for new ESRD beneficiaries did not apply to some ESRD claims correctly. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
ESRD |
N/A |
TOB 72X;
Dates of service 05.01.22 – 06.13.23;
Line item DOS for dialysis is within 120 days of the initial date of first dialysis |
09.29.2023 |
Updates |
09.22.2023 – Another refresh was completed to ensure all affected beneficiary records are correct. See the Provider Action and MAC Action sections below.
07.18.2023 – The refresh mentioned in the Proposed Resolution section below did not update all affected beneficiary records. CMS is still researching, and we will provide updates when they become available. |
MAC Action |
CGS will adjust affected ESRD claims within 120 days of a provider’s request. See Provider Action below. |
Provider Action |
If you identify a claim that meets the criteria above, you may submit a claim adjustment (TOB 727) to correct the claim payment. Please indicate “ESRD Onset Adjustment Correction” in the Remarks field. |
Proposed Resolution |
The coding error was corrected on June 12, 2023, and a refresh of beneficiary records was completed in the CWF on June 13, 2023. |
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