Rejection due to NPI cross walk, Data element missing

Crosswalk did not give 1 to 1 match for NPI 

What this means: The payer does not recognize the provider matched to the NPI tax ID combination in thier system. 

Provider action: Check your NPI and tax ID numbers, are you sending the claim how you are credentialled with the payer, verify this provider is credentialled under the Billing NPI or individual provider NPI.  You may need to contact the payer to retrieve this information? 

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

A data element with 'Must Use' status is missing. Element CR104 

What this means: Some claims submitted October 29, 2012 through November 6, 2012 erroneously rejected with the message, “A data element with 'Must Use' status is missing. Element CR104 (Ambulance Transport Reason Code) is m". 

Provider action: No provider action is required. 

Rejection Removal: Rejections will  be removed by   EDI as they are invalid.

Re-filing:   EDI will re-process the affected claims.

How to avoid or preventing duplicate denial OA 18

Exact duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)

(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)

Resources/tips for avoiding this denial

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.

• Click here to review article on new claim system edits regarding duplicate claims.

• Ensure necessary appropriate modifiers are appended to claim lines.

• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.

Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

Dont call Medicare toll free service line for claim status

Customer service representatives cannot provide claim status via the toll-free service line

Medicare guidelines, specifically, the Internet-only manual (IOM) Publication, 100-09 Chapter 6 Section 50.1 requires that providers call the interactive voice response system (IVR) to obtain claim status.  Service associates responding to calls via our toll-free service line are not allowed to provide claim status.  To do so

would be in violation of Medicare service guidelines.

First Coast Service Options’ (First Coast’s) customer service representatives (CSRs) continue to receive a large volume of calls from providers asking for claim status.  In the majority of cases the calls are coming from entities representing Medicare providers.  Because many providers have chosen to outsource their claims monitoring activities, they may not be aware that the entities representing them are calling the toll-free CSR service line for status of claims instead of using the IVR.

Filing Claim Where General Time Limit Has Expired

As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing. 

Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action. 

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances. 

How claim filing denial calculated from the DOS or receipt date

Determining End Date of Timely Filing Period—Receipt Date 

A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor.  At this point, the submission receives a permanent receipt date that remains part of the claim record.  Once a submission (or claim) passes edits for completeness and validity described , it is accepted into the Medicare claims processing system. 

The receipt date has two functions. It is used for determining whether the claim was timely filed (see 70.4 below). The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary. (See §80 for details on determining claims processing timeliness.)

Determination of Untimely Filing and Resulting Actions

Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”.  As such, the determination that a claim was not filed timely is not subject to appeal.