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Claim Submission Error (CSE) Data

Claim Submission Errors (CSEs) result from an editing process that returns electronic and paper claims to the provider as "unprocessable." This occurs if the claim contains incomplete or invalid information.

Returning a claim as "unprocessable" does not mean CGS will physically return every claim you submit with incomplete or invalid information. The term "Return to Provider" or "RTP" is used to refer to the many processes utilized by CGS for notifying you that your claim cannot be processed. The MA130 remark code on the remittance advice (RA) identifies an RTP claim/service.

RTP claims/services have no Appeal rights, as no "initial determination" can be made on an unprocessable claim/service due to the invalid or incomplete information submitted. This means that these claims cannot be corrected through Redeterminations, the first level of the appeals process. In addition, RTP claims/services do not qualify for correction through the Reopenings process. The error(s) found on these claims/services must be corrected and then resubmitted as NEW claims.

Please note that RTP claims/services create unnecessary costs to the Medicare program so should be avoided.

Below is a list of the monthly top RTP error categories. Refer to resources available to you to avoid future billing errors.

Top Claim Rejections

Kentucky Ohio Description Resource/Reference

# of RTPs: 146,064

# of RTPs:
423,202

Procedure Code Invalid on Date of Service

Code claims using current CPT and HCPCS manuals

  • Codes are valid January - December of each year
  • HIPAA requires the use of codes valid the year the service is rendered
    • Services rendered in CY 2022 must be submitted with 2022 CPT/HCPCS codes
    • Don't forget your CY 2023 manuals!

ANSI Reason or Remark Code: M20

# of RTPs: 5,237

# of RTPs: 11,252

Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer. This includes United Mine Workers of America (UMWA) and Medicare Railroad Beneficiaries (RRB).

Also, be sure to submit Part B services to Part B; Part A services to Part A.

ANSI Reason or Remark Code: N104, N105/N127

# of RTPs: 3,385

# of RTPs: 12,352

Missing/Incomplete/Invalid Ordering/Referring Provider Name and/or Identifier

Some services require ordering/referring provider to be reported on the claim

  • Enter the provider's name and NPI in the electronic equivalent of box 17 and-17b of the CMS-1500 Claim Form
  • Review the CMS-1500 Claim Form / ANSI Crosswalk Job AidPDF for help identifying the fields
  • If information was reported on the claim, verify the physician/practitioner is of a specialty legally allowed to order/refer services for Medicare patients
  • Also verify ordering/referring physician/practitioner is enrolled in PECOS
    • Verifications may be performed by accessing the Ordering/Referring ToolExternal Websiteon the CMS Web site
    • Enter the ordering/referring provider's name on your claim as it appears in the tool.

ANSI Reason or Remark Code: N285/N286

# of RTPs: 2,471

# of RTPs: 9,634

Missing/Incomplete/Invalid Patient Identifier

Be sure to include the correct patient identifier on your claims.

  • The Medicare Beneficiary Identifier (MBI) is the identification number used for processing claims and determining eligibility for services across multiple entities.
  • Use the myCGS MBI Look-Up Tool to obtain a patient's MBI

NOTE: Always bill using the Medicare Beneficiary Identifier (MBI) and name on the red, white, and blue Medicare card.

ANSI Reason or Remark Code: N382

# of RTPs: 2,748

# of RTPs: 8,047

Patient Medicare Identifier / Name Mismatch

Submit the patient's name and Medicare Beneficiary Identifier (MBI) as it appears on their Medicare card

  • Due to a character limit, some Medicare cards don't display patients' full names.
    • According to section 10.2 of the Medicare Claims Processing Manual, Chapter 26External PDF, you should, "Enter the patient's last name, first name, and middle initial, if any, as shown on the patient's Medicare card.
    • Your claims will still process using the name displayed on the patient's Medicare card, even if it isn't their full name.
  • Patient must contact Social Security to make corrections/changes to Medicare card
  • HIPAA does not allow us to verify Medicare IDs

ANSI Reason or Remark Code: 16/MA27/N382

# of RTPs: 1,702

# of RTPs: 8,076

Missing/Incomplete/Invalid Group Practice Information

The complete name, address, NPI, and phone number of the group practice must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form.

Be sure the NPI of the rendering provider relates to the group's NPI.

ANSI Reason or Remark Code: MA112

# of RTPs: 972

# of RTPs: 6,815

Missing/Incomplete/Invalid Rendering/Attending Provider Primary Identifier

When the rendering physician/practitioner is associated with a group practice, his/her NPI must be entered in the electronic equivalent of box 24j of the CMS-1500 Claim Form. The NPI of the group practice must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form. NOTE: Be sure the NPI of the rendering provider relates to the group's NPI.

If the physician is in a solo practice and bills individually, his/her NPI must be entered in the electronic equivalent of box 33 and 33a of the CMS-1500 Claim Form.

ANSI Reason or Remark Code: M79

# of RTPs: 2,378

# of RTPs: 4,129

Missing/Incomplete/Invalid CLIA Certification Number

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 established quality standards for all lab testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed. Labs must apply and obtain a certificate for the CLIA program that corresponds with the complexity of tests performed.

  • Report the 10-digit CLIA certification number for an entity performing CLIA covered services in Item 23 of the CMS-1500 claim form or its electronic equivalent.
  • Services with separate CLIA certificates MUST be submitted on separate claims.
  • Contact the CLIA program with questions or problems with your certification number.

ANSI Reason or Remark Code: MA120/M91

# of Denials:
1,759

# of Denials:
3,098

Missing/Incomplete Primary Payer Information (Medicare is the Secondary Payer)

When Medicare is secondary, the primary payer must be billed first

  • Check this article for steps to help you with MSP claims
  • Be sure to send the primary payer information with your claims
    • Refer to the MSP Job Aid for help identifying the fields needed for an electronic MSP claim
    • If billing on the CMS-1500 claim form, attach a LEGIBLE copy of the primary EOB, clearly identifying the insurer. Be sure the patient is identified on each page and to include the glossary section that defines any codes on the EOB.
  • To verify if there is a payer primary to Medicare:

ANSI Reason or Remark Code: N480

# of RTPs: 869

# of RTPs: 3,178

Invalid/Missing Procedure Code/Modifier Combination

When using a modifier, it must be one that is valid with the procedure code.

  • If service requires a modifier, verify that the correct one is used by accessing the Modifier Finder Tool
  • The patient's medical record must support the use of a modifier

The Provider Contact Center (PCC) cannot tell you which modifier to use on a claim, as they do not have your medical records to determine whether the modifier is appropriately documented.

ANSI Reason or Remark Code: MA130

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