Corporate

April 24, 2013 - Revised: 07.24.19

Claim Status and Corrections

When a claim is submitted to the Fiscal Intermediary Shared System (FISS), multiple editing processes are applied to identify possible errors. The chart below summarizes what happens to a claim that is subject to an edit and the appropriate process available to make claim corrections. Additional information about each claim correction process follows.

Status/Location (S/LOC) Description Action
Claim suspension (SBXXX, SMXXX) No Medicare determination has been made; the claim is still being processed or researched for additional information. You may reference the J15 Part A Claims Processing Issues log to determine if the claim is affected by a system issue that has been reported to CMS/FISS.

Otherwise, you may contact the J15 Part A Provider Contact Center at (866) 590-6703 if the claim has not moved to a finalized location (XB9997) after 30 days (new claim) or 60 days (adjusted claim).
Claim Return to Provider (RTP)

(TB9997)

The claim is missing information necessary to process the claim. The claim can be corrected or resubmitted.
Claim rejection (RB9997) All line items on the claim are rejected. The claim can be adjusted if the tape-to-tape field is blank or resubmitted if there is an "X" in the tape-to-tape field.
Line item rejection (PB9997) There are processed line items on the claim, but one or more line items are rejected. The claim can be adjusted.
Claim denial (DB9997) All line items on the claim are medically denied. A redetermination request may be submitted.
Line item denial (PB9997) There are processed line items on the claim, but one or more line items are medically denied. A redetermination request may be submitted.

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Claim Corrections

  • The claim correction process only applies to RTP claims. A claim correction may be submitted online via the Direct Data Entry (DDE) system.
  • To access RTP claims in the DDE Claims Correction screen, select option 03 (Claims Correction) from the Main Menu and the appropriate menu selection under Claims Correction (21 – Inpatient, 23 – Outpatient, 25 – SNF).
  • RTP claims remain in this location (TB9997) and are available for correction for 180 days.
  • RTP claims are not finalized claims and do not appear on your Remittance Advice (RA). Therefore, you may submit a new (corrected) claim and it will not reject as a duplicate to the original claim.
  • You must submit a new claim if:
    • You do not have access to the DDE system
    • The RTP claim is not corrected within 180 days (or no longer appears in the Claim Correction screen) and becomes inactive (IB9997)
    • The RTP claim was suppressed in error
    • The RTP claim is a canceled claim (Type of Bill (TOB) XX8)

Note: These claims cannot be suppressed.

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Claim Adjustments

  • The claim adjustment process is used to make corrections to processed or rejected claims.  Adjustment claims may be submitted via DDE or your electronic software.
  • Processed and rejected claims are finalized claims and appear on the RA. If a new claim is submitted, it will reject as a duplicate of the original claim.
  • To determine the reason a claim/line item rejected, review the specific reason code assigned and/or the RA.
  • Claim adjustments are subject to the same timely filing limit as new claims (i.e., within one calendar year of the "through" date of service on the claim). A justification statement is required if the adjustment is submitted beyond the timely filing limit.
  • To adjust a claim via DDE, select option 03 (Claims Correction) from the Main Menu and the appropriate menu selection under Claim Adjustments (30 – Inpatient, 31 – Outpatient, 32 – SNF).
  • Claim adjustments must include:
    • TOB XX7
    • The Document Control Number (DCN) of the original claim
    • A claim change condition code and adjustment reason code
    • Optional: remarks to explain the reason for the adjustment. Remarks are required when the default condition code D9 and adjustment reason code OT are used.
  • The following claims cannot be adjusted:
    • Claims that did not post to the Common Working File (CWF) and contain an "X" in the tape to tape field; you must submit a new claim.
      • These claims do not appear in the claim adjustments screen. To view the tape to tape field: select option 01 (Inquiries) from the Main Menu, select option 12 (Claim Summary), select the claim, go to page 2, press F2.
    • Denied claims or claims with denied line items.
    • Claims that were adjusted based on a medical review determination; a redetermination request may be submitted. These claims are identified as follows:
      • Comprehensive Error Rate Testing (CERT) or Recovery Auditor contractor decisions = TOB XXH
      • Office of Inspector General (OIG) decisions = TOB XXK

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Claim Voids/Cancels

  • The claim void/cancel process is only used if a processed claim should never have been submitted.
  • To cancel a claim via DDE, select option 03 (Claims Correction) from the Main Menu and the appropriate menu selection under Claim Cancels (50 – Inpatient, 51 – Outpatient, 52 – SNF).
  • Void/cancel claims must contain:
    • TOB XX8
    • The DCN of the original claim
    • Condition code D5 (incorrect Medicare ID number or National Provider Identifier (NPI) submitted) or D6 (duplicate payment or other error)
    • Optional (recommended): remarks to document the reason for voiding/canceling the claim.

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Clerical Error Reopenings

  • The claim reopening process is available to correct clerical errors when the claim is beyond the timely filing limit.
  • CMS defines clerical errors (including minor errors or omissions) as human or mechanical errors on the part of the provider or the contractor, such as:
    • Mathematical or computational mistakes
    • Transposed procedure or diagnostic codes
    • Inaccurate data entry
    • Misapplication of a fee schedule
    • Computer errors
    • Denial of claims as duplicates which the party believes were incorrectly identified as a duplicate
    • Incorrect data items, such as provider number, use of a modifier or date of service
  • To request a claim reopening, complete the Clerical Error Reopening Request formPDFand mail it along with the corrected claim form to the J15 Part A Claims Department address listed on the form.
  • To submit a claim reopening via DDE or your electronic software, please reference the following:
    • MM8581External PDF "Automation of the Request for Reopening Claims Process"
    • SE1426External PDF "Scenarios and Coding Instructions for Submitting Requests to Reopen Claims that are Beyond the Claim Filing Timeframes – Companion Information to MM8581: "Automation of the Request for Reopening Claims Process"

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Overpayments

  • MSP Overpayments
    • If you identify an overpayment (e.g., due to a billing error or MSP involvement), you should submit an electronic adjustment or void the claim.
    • If you are not able to submit the adjustment/void, identify the overpayment on your quarterly credit balance report.
  • Section 935 Overpayments

    If a full or partial overpayment is identified through the medical review process (i.e., due to a review by CGS, CERT, the Recovery Auditor, etc.):

    • Immediate Offset:
      • You may request an immediate offset of the overpayment so that recoupment begins immediately and the amount of interest assessed is reduced or eliminated.
      • To request an immediate offset, complete and mail/fax the Immediate Offset Request FormPDF or submit the request via the myCGS Portal.
      • If recoupment of the overpayment is satisfied within 30 days, no interest is charged. If sufficient funds are not available for recoupment and the overpayment does not collect in full within 30 days of the demand letter, interest will be assessed on the outstanding principal balance.
      • If you plan to submit an immediate offset request and file a redetermination, please wait for the immediate offset to take effect before filing the redetermination.
    • Rebuttal Process:
      • If recoupment of the overpayment will cause a financial hardship and should not take place, you may submit a statement and accompanying evidence to CGS within 15 days of the date of the demand letter.
      • A rebuttal is not intended to review supporting medical documentation or disagreement with the overpayment decision.
      • A rebuttal statement does not necessarily stop the recoupment process. To stop the recoupment process, providers must submit a valid redetermination request.

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Medical Review Additional Development Request (ADR)

  • The ADR process is used to notify you that a claim has been selected for medical review and is a request for you to send any medical documentation that supports the service(s) rendered and billed.
  • CGS mails ADR letters to the correspondence address listed on the provider file (Section 2C of the CMS-855A form).
  • To identify claims selected for medical review in DDE, select option 01 (Inquiries), option 12 (Claims), key the National Provider Identifier (NPI), tab to the S/LOC field, type SB6001, and press Enter. Select the claim; the ADR begins on claim page 7. You may print the ADR letter or copy and paste it into a Word document.
  • You may also identify claims selected for medical review and respond electronically in the myCGS Portal.
  • Send a copy of the ADR letter and your medical documentation to the address indicated in the letter.
  • If your documentation is not received within 45 days, the claim will be denied with reason code 56900.

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Redeterminations (Appeals)

  • The redetermination process is the first level of appeal and applies to a claim or line item that receives a full or partial denial (identified as a claim in location DB9997 or a claim/line level reason code that begins with the number five or seven).
  • If your claim was denied for non-receipt of records in response to an ADR (reason code 56900), or if you do not agree with a denial of a service, you may request a redetermination by completing the Redetermination Request FormPDF and mail it along with any required and supporting documentation to the address listed on the form.
  • You may also complete the form and submit your documentation electronically in the myCGS Portal.
  • Redetermination requests must be submitted within 120 days of the date on the Remittance Advice (RA).
  • Inappropriate requests for redeterminations:
    • Items not denied due to medical necessity
    • Clerical errors that can be handled as online adjustments or clerical reopenings
    • Requests for timely filing extensions
    • Provider overlap billing disputes

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