CorporateBusiness Services

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
11.15.2017 Pending All providers 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. N/A N/A  
Updates
MAC Action N/A
Provider Action 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 On December 8, 2017, CMS systems will revert back to the previous display of patient responsibility for QMBs on the Medicare RA.

Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
11.06.2017 Pending 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  
Updates

11.06.17 – 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

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

11.06.17 – 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


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
10.11.2017 Pending ESRD Claims were rejecting in error 36341 N/A  
Updates

10.19.17 – CGS has deployed a workaround so that claims submitted after 10.11.17 will not be impacted by this error.

10.11.17 – The FISS is aware of the issue and is currently researching.

MAC Action

CGS will initiate a Mass Adjustment on 11.06.17 for claims that may have rejected at the claim-level.

Provider Action

10.19.17 –For rejected claims that have an 'X' tape to tape flag, providers will need to resubmit the claim for processing. Providers who have Direct Data Entry (DDE) may go to page 2 of the claim and F2, and the tape to tape flag will be indicated on TPE-TO-TPE field on MAP171D.

Proposed Resolution

See MAC Action


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
09.08.2017 Resolved Hospitals Claims submitted with HCPCS code J9217 and diagnosis code C61 denied in error. 55503 – Claim level, 53139 – Line level N/A 10.11.2017
Updates

10.11.2017 - Adjustments have been completed.

09.08.2017 - CGS will correct the edit and adjust claims denied in error. Estimated completion date is October 1, 2017.

MAC Action

10.11.2017 - CGS has completed adjustments to reprocess claims denied in error.

Provider Action

10.11.2017 - Providers should review their remittance advices to identify the adjusted claims.

Proposed Resolution

N/A


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
08.25.2017 Resolved Hospitals Claims are denying at the claim level instead of the line level with the appropriate line level reason code. 55503 – Claim level, 53101, 53105, 53107 – Line level N/A 10.11.2017
Updates

10.11.2017 - Claim adjustments have been completed.

08.25.2017 - CGS will identify and adjust claims denied in error. This will include claims that are pending appeal decisions.

MAC Action

09.08.2017 - CGS has completed adjustments to reprocess claims denied in error.

Provider Action

10.11.2017 - Providers should review their remittance advices to identify the adjusted claims.

Proposed Resolution

N/A


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
06.09.2017 Pending All Part A Providers who bill Outpatient  Claims Some claims RTPd in error due to an issue with the HCPC file. 32402, 32403, 32404 Verify the revenue/HCPCS code combination in the Direct Data Entry (DDE) HCPC Codes Inquiry Menu 14  
Updates

10.11.2017 - HCPCS that had incorrect associated revenue codes have been corrected, or are currently being corrected. This process will be complete on October 27, 2017.

06.19.2017 - CGS is aware that some claims are RTPd in error and is researching and updating the appropriate files.

MAC Action

HCPCS codes that had incorrect revenue codes listed are actively being corrected with an anticipated completion date of October 27, 2017.

Provider Action

Providers should F9 or resubmit claims that were RTP'd in error. If there are still issues after October 27, 2017, contact the PCC. For claims that are RTPd with reason code 32403, verify if the code is still valid in the DDE HCPC Inquiry Menu 14.

Proposed Resolution

N/A


Two Vantage Way, Nashville, TN 37228 ©2017 CGS Administrators, LLC. All Rights Reserved