2006 Physician Group Provider Workshop

Transcription

1 January 20, 2006 Top Denials for Physician Group Providers 2006 Physician Group Provider Workshop Conduent MS Medicaid Project Government Healthcare Solutions

2 Edit 0029 Service not Family Planning related Edit 0032 Claim Type cannot be assigned Edit 0104 Exact Duplicate Claim Providers are submitting codes that are not related to Family Planning Program. Provider has submitted a claim with a provider number which cannot be assigned a claim type. Exact Duplicate Claim Verify that the procedure and diagnosis code are from the Family Planning Program procedure/diagnosis list on the Division of Medicaid websitewww.dom.state.ms.us Verify the provider number is correct and active. When verification is complete, refile the claim. This issue is currently under review by our systems department. Testing is being conducted. No action is needed on the providers part at this time. 2

3 Edit 0105 Suspect Duplicate Claim Provider has billed a claim that has a date of service (DOS) which paid to another provider. This issue is currently under review by our systems department. Testing is being conducted. No action is necessary on the providers part at this Edit Beneficiary ID is Missing/Invalid Edit 0132 Submitted charges are missing Provider has submitted a claim with a missing or invalid Medicaid ID number. A claim has been processed without submitted or billed charges time. Verify beneficiary s ID number, correct the claim, and resubmit. Verify the charge submitted was on your claim and keyed correctly. Make correction and refile your claim. 3

4 Edit 0142 Beneficiary not eligible *Recycle* Provider has submitted a claim on a newly eligible beneficiary. Edit will suspend for 21 days and no action is necessary during this time. On the 22 nd day, the claim will deny for edit 0143 if eligibility is not found. If eligibility is found, the claim should Edit Beneficiary not Eligible/Not Found Edit 0221 Beneficiary Name Mismatch Provider has submitted a claim for a beneficiary who is not currently eligible nor on file as a Medicaid beneficiary. Provider has submitted a claim with an invalid name. adjudicate appropriately. Verify the beneficiary s eligibility and resubmit the claim. Verify beneficiary s name as it appears in the Mississippi Medicaid system, correct the claim, and resubmit. 4

5 Edit 0265 Medicare Part B Elig. W/O Attach Edit 0313 Category of Service cannot be determined Edit 0367 Procedure Service Provider Type Conflict A claim has been submitted for a beneficiary who has Medicare Part B and no EOMB was filed with the claim. Provider has submitted a claim with an invalid billing provider number. The provider has submitted a claim with a procedure that conflicts with the servicing provider type. Refile the claim by hardcopy and include EOMB from Medicare. Verify the billing provider number was keyed correctly and is an active provider number. If not, correct and refile your claim. Verify the provider number and procedure billed. Make corrections and refile your claim. 5

6 Edit 0422 Servicing Provider not enrolled Edit 0423 Servicing Provider not in billing group Edit 0439 Procedure not a benefit for service date A claim has been submitted with a servicing provider number that is not enrolled in our Mississippi Medicaid program. A claim has been submitted with an invalid servicing provider number or the servicing provider number is not associated with the group. Provider has billed a claim with a procedure code that is not valid or covered for the dates billed. Verify the servicing provider number was keyed correctly and is a valid number. If corrections are needed, make those corrections and refile your claim. Verify the servicing provider number. Make correction and refile your claim. Verify if the procedure code and date of service were keyed correctly. If so, verify that the procedure code is valid for the date of service. 6

7 Edit 0546 Procedure Requires Price Provider has submitted a procedure Provider must submit a claim hardcopy that requires manual pricing. to Conduent with appropriate Edit 0750 TPL - Beneficiary has primary insurance. Resubmit with TPL EOB Edit 1000 Anesthesia must bill with modifier Provider has submitted a claim to Medicaid as primary. Beneficiary has another insurance carrier. Anesthesia providers are billing without an anesthesia modifier. documentation for medical review. Provider must resubmit claim to the primary insurance first, then to Medicaid as secondary. Anesthesia providers MUST bill with an anesthesia modifier. 7

8 Edit 3222 Provider name/number mismatch This is a paper edit only. This means the provider name and number located in field 33 of the CMS do not match what Medicaid has on file. Check for the following information on your claim form: For a provider filing under an individual provider number, make sure that in form locator 33 of the CMS-1500 the provider s name is in last name, first name order along with the individual s provider number. For providers filing under the group number, make sure in form locator 33 the group name appears as Medicaid shows it on your remittance advice. Make corrections and refile your claim. 8

9 Edit 3259 Claim exceeds Filing Time Limit Edit 3272 Date of Service (DOS) greater than 1 year with no Timely Filing (TF) Transaction Control Number (TCN) Edit 3435 ClaimCheck procedure incidental/integral to another procedure This is the timely filing edit for crossover claims. If the claim is received at Conduent more than 180 days from the Medicare pay date, the claim will deny with this edit. The claim is more than 12 months from the DOS and does not have a timely filing TCN on the claim. The provider has billed a procedure that is incidental or performed at the same time as a more complex primary procedure. Unlike straight Medicaid claims, there is not a timely filing TCN for crossover claims. If the claim is beyond 180 days, there is nothing else that can be done. Identify the 17 digit timely filing TCN. (Make sure the TCN selected is not a voided or adjusted TCN.) Submit that TCN on your claim for reprocessing. The incidental procedure is clinically essential to the primary procedure. Thus, the denial for this edit would be a correct denial. 9

10 Edit 3708 Physician Office visit exceeded A claim has been submitted for a beneficiary who has exceeded their physician office visit limits for the fiscal year. Verify office visits have been exceeded. If so, this would be a correct denial and the claim should not be refiled. Edit 3715 Physician Inpatient SVC limit exceeded A claim has been submitted for a beneficiary who has exceeded their physician inpatient office limit for the fiscal year. Note: Children under 21 can receive additional service limits through the EPSDT program. Verify physician inpatient visits have been exceeded. If so, this would be a correct denial and the claim should not be refiled. Note: Children under 21 can receive additional service limits through the EPSDT program. 10

11 Edit 0230 Provider not allowed to bill PC/TC (Professional Component, Technical Component) The provider is billing a procedure which does not require a modifier such as 26 or TC. Edit 0325 Trauma/Accident claim Edit 0771 TPL - Pay/Report Cost Avoid, TPL $ on Claim, Send Inquiry Edit 0775 TPL - Pay/Report TPL Attachment A claim has been submitted due to trauma or an accident. This exception code is used by the Division of Medicaid and Conduent for reporting purposes. This exception code is used by the Division of Medicaid and Conduent for reporting purposes. This is a pay and report edit. No action is needed on the provider s part. This is a pay and report edit. No action is needed on the provider s part. No action required by the provider. No action is required by the provider. 11

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