2005 Hospital Provider Workshop

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Cathleen Gray
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1 August 26, 2005 Top Denials for Hospital Providers 2005 Hospital Provider Workshop Conduent MS Medicaid Project Government Healthcare Solutions

2 Edit 0029 Service not Family Planning related Edit 0104 Exact Duplicate Claim Edit 0105 Suspect Duplicate Claim Providers are submitting codes that are not related to Family Planning Program. Exact Duplicate Claim Provider has billed a claim that has a date of service (DOS) which paid to another provider. 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 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. This issue is currently under review by our systems department. Testing is being conducted. No action is necessary on the providers part at this time. 2

3 Edit Beneficiary ID is Missing/Invalid Provider has submitted a claim with a missing or invalid Medicaid ID number. Verify beneficiary s ID number, correct the claim, and resubmit. 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 22nd day, the claim will deny for edit 0143 if eligibility is not found. If eligibility is found, the claim Edit Beneficiary not Eligible/Not Found Provider has submitted a claim for a beneficiary who is not currently eligible nor on file as a Medicaid beneficiary. should adjudicate appropriately. Verify the beneficiary s eligibility and resubmit the claim. 3

4 Edit 0148 Revenue Code Missing A revenue code did not appear on the claim during processing. Ensure revenue code transmitted if billed electronically. If billed hard copy, ensure revenue code was keyed from the claim. Edit 0172 Procedure Code Missing Edit 0221 Beneficiary Name Mismatch A procedure code did not appear on the claim during processing. Provider has submitted a claim with an invalid name. If revenue code was not on the claim, correct and rebill. Ensure procedure code transmitted if billed electronically. If billed hard copy, ensure procedure code was keyed from the claim. If procedure code was not on the claim, correct and rebill. Verify beneficiary s name as it appears in the Mississippi Medicaid system, correct the claim, and resubmit. 4

5 Edit 0238 Submitted units exceed Provider has billed a code with more Verify the number of units allowed and maximum allowed units units than allowed by the Division of re-file the claim. Edit 0439 Procedure not a benefit for service date Edit 0544 Revenue code not valid for dates of service Edit 0675 Consent Required Medicaid for that procedure code. Provider has billed a claim with a procedure code that is not valid or covered for the dates billed. The provider is billing a revenue code that is not valid or covered for the dates billed. Provider has billed a claim that requires a consent form and there is no valid consent form on file. 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. Verify if the revenue code and date of service were keyed correctly. If so, verify that the revenue code is valid for the date of service. Verify consent form is on file and refile your claim. 5

6 Edit 0718 No Deductible/Coinsurance on crossover claim Edit 0750 TPL - Beneficiary has primary insurance. Resubmit with TPL EOB Edit 0870 Type of bill is missing/invalid Medicare has not crossed over a deductible/coinsurance or provider did not submit a deductible/coinsurance on claim. Provider has submitted a claim to Medicaid as primary. Beneficiary has another insurance carrier. Provider is using a bill type that is invalid or missing or a bill type that has not been loaded in the system. (i.e. Adj./Void bill types) Verify if there is deductible and/or coinsurance owed. If so, resubmit the claim within 180 days of the Medicare paid date with the appropriate information on the claim and the EOMB. Provider must resubmit claim to the primary insurance first, then to Medicaid as secondary. Verify the bill type submitted, correct the claim, and resubmit. Note: If it is a bill type not yet loaded, please contact your Provider Field Representative for assistance. 6

7 Edit 1471 Surgery procedure/revenue conflict Edit 1700 HCPCS code must be lab Edit 3706 Outpatient visits SL exceeded Edit 0302 Attending Provider is not on file Provider is billing a surgery procedure code without a surgery revenue code. Provider is not billing a HCPCS code with revenue code for lab services. Provider has billed a claim for a beneficiary who has used all outpatient visits for the fiscal year. Provider has submitted a claim with an attending provider s information which is not on file. When billing a surgery procedure code, a surgery revenue code must accompany the procedure code. This revenue code range is When billing lab services, the provider must enter the revenue code and the HCPCS procedure code. Verify service limits. If it is a child under 21, complete a Plan of Care Form for extended services. If the beneficiary is over 21 and has no outpatient visits, this claim has denied correctly. This edit is for tracking purposes only. No action is required by the provider. 7

8 Edit 0771 TPL - Pay/Report Cost This exception code is used by the No action required by the provider. Avoid, TPL $ on Claim, Send Inquiry Division of Medicaid and Conduent for Edit 0775 TPL - Pay/Report TPL Attachment Edit 0777 TPL - Pay and chase - absent parent Edit 0779 TPL - Pay and chase, report attachment reporting purposes. This exception code is used by the Division of Medicaid and Conduent for reporting purposes. This exception code is used by DOM and Conduent for reporting purposes. This exception code is used by the Division of Medicaid and Conduent for reporting purposes. No action is required by the provider. No action is required by the provider. No action is required by the provider. 8

2006 Physician Group Provider Workshop

January 20, 2006 Top Denials for Physician Group Providers 2006 Physician Group Provider Workshop Conduent MS Medicaid Project Government Healthcare Solutions Edit 0029 Service not Family Planning related