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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.

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

5.30.18

Open

Part B providers in Ohio that may bill CPT codes 0449T or 0450T in ASC or for assistant surgeon

CPT codes 0449T and 0450T were to be end dated on a Category III CPT code edit.  TOS F (Ambulatory Surgical Center) and TOS 8 (assistant-at-surgery) were mistakenly left as active.

N/A

CPT codes 0449T and 0450T

 
Updates

05.13.2018 – Obtaining a list of claims data

MAC Action

We will pull a list of claims billed for TOS F and TOS 8 in Ohio for these codes and adjust.

Provider Action

No action required of you.

Proposed Resolution

Adjust applicable claims


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

2.27.18

Open

Occupational Therapists, Physical Therapists, Speech-Language Pathologists, Ambulance Suppliers

The provisions affecting outpatient therapy services expired 12/31/2017. The new provision required the continued submission of HCPCS modifier KX for services in excess of the prior therapy cap amount for claims with dates of service on and after January 1, 2018. Due to a systems issue, services billed with HCPCS modifier KX in excess of the prior therapy cap amount were denied.

CR 10531 also affects payment of 2018 services rendered by Ambulance suppliers.

Additional, MPFS claims for localities and States impacted by the Work GPCI Floor fee increase for Dates of Service in CY 2018.

N/A

Therapy Services, Ambulance Services

N/A
Updates

05.29.2018 – Adjustments for Ambulance fee schedule services rendered in 2018 have begun. We will provide another update as other adjustments begin.

05.10.2018 – HCPCS modifier KX adjustments are pending. We will provide an update when the adjustments begin.

04.11.2018 – Contractors have six months to reprocess these claims.

03.29.2018 – Change Request (CR) 10531 (MLN Matters article MM10531External PDF) indicated contractors shall automatically reprocess therapy claims with the KX modifier containing dates of service in calendar year 2018, which were denied prior to the implementation of the updated legislative effective dates. In addition, contractors shall automatically reprocess therapy claims with the KX modifier that were denied due to an invalid date provided in instructions. The automatic reprocessing will begin on 4/2/2018 or shortly thereafter.

03.13.2018 – CMS is going to issue instructions on reprocessing claims affected by this legislation.

MAC Action

Follow above directions from CMS

Provider Action

No action required of you.

Proposed Resolution

Reprocess claims beginning 4/2/2018


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

4.19.18

Closed

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.

N/A

MolDx CPT codes 87507 and 87999

Closed
Updates

05.18.2018 – Claims identified for Part B have been adjusted.

05.03.2018 – We have obtained all data needed to review. Verifying services submitted with CPT code 87999 are for BioFire test before adjusting and to determine timeframe needed to complete adjustments.

MAC Action

We are currently analyzing data back to 01.01.2017 to determine validity and our next steps.

Provider Action

No action required of you.

Proposed Resolution

Adjust affected claims


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

03.14.18

Closed

Those who submit claims for Molecular Diagnostic (MolDX) test

Our processing system is denying codes for mismatch MolDX/no MolDX ID submitted on the claim.

N/A

Lab codes for MolDX: CPT codes 81105-81595, 87505-87507, 87631-87633, 86152-86153, 0001U-0023U, 0001M-0010M

N/A

Updates

04.06.2018 – The affected claims identified have been adjusted.

03.23.2018 – The issue has been addressed and claims started processing correctly as of 03.16.2018. Adjustments will be made to affected claims.

MAC Action Investigating system issue to determine resolution.
Provider Action No action required of you.
Proposed Resolution CGS will pull affected claims and adjust them.

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

2.27.18

Closed

Various Part B Providers

Change Request (CR) 10262 addressed the January 2018 CWF update to Skilled Nursing Facility (SNF) Consolidated Billing edits. As a result, changes to the editing inadvertently are causing claims for non-therapy, ambulance services to or from dialysis facilities and physicians professional services to deny in error.

Refer to MM10262External PDF for additional information.

N/A

Ambulance and Physician Professional services

02.28.18
Updates

02.28.18 – CGS is working to identify all claims denied in error to mass adjust.

MAC Action

The CWF Maintainer has been contacted and advised of the issue.

Provider Action

Until a corrective action occurs, if an overpayment has already been requested, it is recommended for a provider to submit an appeal. When appealing, please include a copy of the demand letter. This will prevent the incorrect recoupment of funds. It is also recommended to hold future claim submissions that meet the criteria outlined to prevent erroneous denials.

Proposed Resolution

Awaiting to learn of a solution.


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

01.16.18

Closed

Providers who submit therapy services

CMS is instructing contractors to hold claims for dates of service in 2018, submitted for therapy services and containing HCPCS modifier KX, until further notice.

N/A

Therapy services

02.28.18
Updates

02.28.18 – All claims held have been released.

01.30.2018 – Starting January 25, 2018, CMS will immediately release for processing held therapy claims with HCPCS modifier KX with dates of receipt beginning from January 1-10, 2018. Then, starting January 31, 2018, CMS will release for processing the held claims one day at a time based on the date the claim was received, i.e., on a first-in, first-out basis. At the same time, CMS will hold all newly received therapy claims with HCPCS modifier KX and implement a "rolling hold" of 20 days of claims to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries if legislation regarding therapy caps is enacted. For example, on January 31, 2018, CMS will hold all therapy claims with HCPCS modifier KX received that day and release for processing the held claims received on January 11, 2018. Similarly, on February 1, 2018, CMS will hold all therapy claims with HCPCS modifier KX received that day and release for processing the held claims received on January 12, and so on.

Under current law, CMS may not pay electronic claims sooner than 14 calendar days (29 days for paper claims) after the date of receipt, but generally pays clean claims within 30 days of receipt

MAC Action
Provider Action

N/A

Proposed Resolution

Waiting for additional direction from CMS


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

01.25.2018

Closed

All providers

The Interactive Voice Response (IVR) system is not calculating the QMB deductible and coinsurance amounts correctly.

NA

NA

02/12/2018

Updates

02.14.2018 – This issue has been resolved.

MAC Action

01.25.2018 – CGS is working to resolve this issue.

Provider Action

02.14.2018 – Providers can now use the IVR (1.866.290.4036) to obtain a breakdown of the deductible and coinsurance amounts.
01.25.2018 – At this time, please contact the Part B Provider Contact Center (PCC) at 1.866.276.9558 for assistance in getting a breakdown of the deductible and coinsurance amounts.

Proposed Resolution  

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

01.24.18

Closed

Primarily Independent Clinical Labs

Effective for claims with line item dates of service on and after January 1, 2018, contractors shall not bundle or roll up individually billed lab test HCPCS code to a lab panel HCPCS code or an ATP code.

N/A

G0058, G0060, 80048, 80053, 80069, 82040, 82248, 82251, 82330, 82435, 82550, 82947, 83615, 84100, 84155, 84450, 84478, 84550, G0059, 80047, 80051, 80061, 80076, 82247, 82250, 82310, 82374, 82465, 82565, 82977,84075, 84132, 84295, 84460, 84520, 80072, 83718, 85651, 86430, 86694, 86709, 86777, 87340, 80049, 80074

01.25.18

Updates

CGS has identified some of the system settings to turn off lab panel HCPCS were not set correctly. CGS has corrected the settings.

MAC Action

System updates were corrected and CGS will adjust the impacted claims.

Provider Action

N/A

Proposed Resolution

System issues were corrected.


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

01.01.18

Closed

Part B Providers/ Suppliers

Claims held due to the January 2018 release

N/A

All 2018 dates of service

01.17.18

Updates

N/A

MAC Action

All claims released 01.17.18

Provider Action

N/A

Proposed Resolution

N/A


Date Reported Status Provider Type Impacted Description of Issue Reason Codes Claim Coding Impact Date Resolved
11.15.2017 Closed 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 03.16.2018 – Per CR10494External PDF, CGS will initiate adjustments for QMB claims with a date of receipt prior to 12.08.2017. The adjustment is to produce "replacement" Medicare RAs that providers can submit to supplemental payers to coordinate benefits as necessary. All adjustments will be complete by December 20, 2018.
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 IssueExternal PDF 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.

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