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Claim Payment Alerts
Please reference this page for information about confirmed, system-related issues before you reach out to Customer Service. Click on the description to view details and check back often for updates that we post when they become available.
Closed issues remain on the active log for approximately 60 days before they move to the resolved issues archive list at the bottom of the page.
If you still have questions, please contact Customer Service or use one of our self-service tools.
| Date Reported |
Description of Issue |
| 04.10.2026 |
This is an addendum to the 04/08/2026 CPIL regarding E & M codes denying in error. Services were denied as payment made for same/similar procedure within set time frame. We've identified QPP Mass Adjustments are also impacted. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Part B Providers |
|
E/M CODES |
|
Updates |
This is an addendum to the 04/08/2026 CPIL regarding E & M codes denying in error. E&M Services denied in error due to the system logic indicating payment issued for same/similar procedure within set time frame. This impacts claims and QPP adjustments. |
MAC Action |
CGS WILL TAKE NECESSARY STEPS TO ISSUE CORRECT PAYMENT AND CANCEL OVERPAYMENT AS IDENTIFIED. |
Provider Action |
There is no action required by providers – please refrain from calling the provider call center and/or submitting reopenings or appeals. CGS is actively pursuing corrective action. |
Proposed Resolution |
Identify claims & mass adjustments impacted by system audit requiring payment where E&M services were denied; issue payment as needed. |
|
| 04.08.2026 |
Evaluation and Management codes denying in error indicating service denied because payment already made for same/similar procedure within set time frame. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Physicians and Non-physicians practitioners in KY |
97 (with M86 & N20) |
E/M CODES |
|
MAC Action |
CGS will identify claims processed & denied in error. Mass adjustments will be initiated to allow payment for claims denied in error. |
Provider Action |
No action is required. Do not send claims to appeals. |
Proposed Resolution |
CGS is initiating changes to system edits to prevent services denying in error. |
|
| 03.10.2026 |
Quality Payment Program: Claim Adjustments to Correct Conversion Factor - Starting in CY 2026, the update to the qualifying alternative payment model (APM) conversion factor is +0.75%, while the update to the nonqualifying APM conversion factor is +0.25%. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Physicians and Practitioners |
N/A |
N/A |
02.26.2026 |
MAC Action |
CGS will adjust affected claims processed January 1 – February 26, 2026. |
Provider Action |
No action is required. |
Proposed Resolution |
CMS identified inaccurate Medicare Physician Fee Schedule payments to some Quality Payment Program physicians and practitioners. MACs are instructed to adjust all affected claims. MLN Connects Newsletter for March 12, 2026 . |
|
| 02.11.2026 |
Denials for vaccine codes when billed by pharmacies (specialty A5 type 50) in KY |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Specialty A5/Ttype 50 Pharmacies in KY |
B7 |
90653-90732 |
|
MAC Action |
TYPE 50 HAS BEEN ADDED TO THESE CODES AS OF 1/22/26 |
Provider Action |
Providers can submit a reopening for these incorrect denials |
Proposed Resolution |
|
|
| 01.13.2026 |
E & M SERVICES CONCURRENT CARE |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Physicians and
Non-physicians practitioners |
|
E/M CODES |
|
MAC Action |
CGS INITIATED CHANGES TO PREVENT CLAIMS FROM DENYING IN ERROR FOR CONCURRENT CARE |
Provider Action |
NO ACTION NEEDED |
Proposed Resolution |
THIS IS AN ADDENDUM TO THE CPIL DATED 1/13 - PROVIDERS DO NOT NEED TO FILE AN APPEAL, A MASS ADJUSTMENT IS IN PLACE TO ADDRESS PAYMENT ERRORS. |
|
| 12.10.2025 |
Certain clinical laboratory test claims with dates of service on October 1 – December 1, 2025, denied in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Part B |
CWF edit 8618 |
CLIA waived tests (QW modifier) |
12.01.2025 |
MAC Action |
CGS will reprocess impacted claims within 30 calendar days. |
Provider Action |
N/A |
Proposed Resolution |
Claims won't deny on or after December 1, 2025. CGS will reprocess claims. You don't need to take any action. |
|
| 11.21.2025 |
Claims for COVID and other vaccines provided on the same day denied in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Part B |
|
Date of service 10.01.2025 or after; CPT code 90480 |
12.03.2025 |
MAC Action |
12.03.2025 – CGS received the January 2026 NCCI PTP edits file to download. Within 30 business days, we'll adjust impacted claims or adjudicate appeals to allow payment if there's no other reason to deny. |
Provider Action |
N/A |
Proposed Resolution |
This issue is a result of National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) edits tied to CPT code 90480 (COVID vaccine administration) implemented on October 1, 2025. Therefore, CMS is expediting the implementation of the January 2026 NCCI PTP edits file. |
|
| 11.07.2025 |
The Common Working File (CWF) Host identified an issue that caused a subset of HMO beneficiary claims to deny (no open HMO enrollment) in error. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Part B |
Audit 341A, CWF error code 5232 |
|
11.13.2025 |
MAC Action |
11.24.2025 – We released all suspended claims, and new claims should process as usual.
11.18.2025 – The CWF Host sent a list of impacted HMO beneficiaries. Within 30 days, we'll adjust claims denied in error.
Suspend claims (location 240) until the issue is resolved. |
Provider Action |
N/A |
Proposed Resolution |
11.13.2025 – The issue is resolved. Due to volume, we'll release claims in batches.
CGS will provide updates once the CWF Host notifies us that the issue is resolved. |
|
| 11.05.2025 |
Clinical Lab Service denying due to a missing, incomplete, or invalid Clinical Laboratory Improvement Amendments (CLIA) certification number. |
| Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Part B (KY and OH) |
MA 120 and 284 |
Clinical Laboratory |
|
| MAC Action |
N/A |
| Provider Action |
Ensure your laboratory's CLIA certification is current and covers all billed specialties and subspecialties. |
| Proposed Resolution |
Contact your state's CLIA office to verify your certification status including billed specialties and subspecialties. Resubmit claims.
CLIA offices:
Kentucky
Ohio |
|
Updated: 04.13.2026