Avoiding reject reason code U5200 and U5233

Q: We are receiving reason code U5200, indicating no record of Part A entitlement for the beneficiary. What steps can we take to avoid this reject?

Reason Code : U5200

Description: NO ENTITLEMENT - THERE IS NO RECORD OF THE BENEFICIARY'S ENTITLEMENT TO THE TYPE OF SERVICES SHOWN ON THE CLAIM.

A: Check beneficiary eligibility prior to submitting claims to Medicare.

Ways to verify beneficiary eligibility:

To access the status of a claim or a beneficiary's Medicare eligibility information (including the date of birth, date of death, entitlement dates, benefit dates, deductible, or coinsurance) use these options below.

Prior to providing services, obtain a copy of the beneficiary’s Medicare card and verify the beneficiary’s insurance information with either the beneficiary or his/her legal representative.
Part A providers

• Contact the Part A interactive voice response (IVR) system at 877-602-8816.
• Direct data entry (DDE) users -- by using the ELGA (eligibility A) screen, you can obtain eligibility information on any beneficiary for whom you are submitting claims.
• 270/271 eligibility transactions -- this is also a real time inquiry, and you can obtain the eligibility information in a batch format for a number of beneficiaries.
Part B providers
• Contact the Part B IVR at 877-847-4992.
Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
Be sure to take advantage of the Secure Provider Online Tool (SPOT), where you can also view claims status, eligibility and benefits, payment information, and comparative billing data in a secure online environment.


MSP claim rejection FAQ
Q. If a claim is rejected for Medicare as a secondary payer (MSP) and the common working file (CWF) is updated, what action should be taken on the claim?

A. Follow the guidelines below if your claim falls within the status outlined:
• If your claim has rejected ("R" status), you should be able to adjust the claim and resubmit through your electronic software.
• If the claim has been returned to provider ("T" status), you should correct the errors and resubmit through your electronic software.
Remember you can only void/cancel a paid claim.



Reject reason code U5233 

Q: We are receiving reject reason code U5233. What steps can we take to avoid this reason code?
Reason Code: U5233
Description : FOR PPS CLAIMS, AND CLAIMS WITH PROVIDER NUMBERS BEGINNING WITH '210', THE ADMISSION DATE FALLS WITHIN A RISK GHO PAID PERIOD, BUT NO GHO PAID CODE OR CONDITION CODE '69', IS INDICATED ON THE CLAIM. OR FOR NON-PPS INPATIENT AND SNF CLAIMS, THE STATEMENT DA TES FALL WITHIN, OR OVERLAP A RISK GHO PERIOD, BUT NO GHO PAID CODE OR CONDITION CODE '69' IS INDICATED ON THE CLAIM.

A: You are receiving this reason code which indicates the admission date falls within a risk Group Health Organization (GHO) paid period. The beneficiary was/is enrolled in a Medicare replacement plan for the date of service(s) billed and the claim should be filed to that plan for payment
Many times a claim will overlap a GHO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim.
There are several ways to obtain beneficiary eligibility to determine if in a GHO:
1. Users can access eligibility information via direct data entry (DDE) .
2. Contact the interactive voice response (IVR) system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
3. 270/271 eligibility transactions -- you can obtain eligibility information in a batch format for a number of beneficiaries.
4. Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
5. Upon admission for Medicare covered services, review all insurance card(s) the beneficiary may hold and verify the information on the card with the patient or their legal representative and determine if all the information is still valid.
To bill for indirect medical education (IME), use the following guidelines:
• Your facility must be an approved facility in order to bill IME
• Type of bill = 11x
• Condition code 04 and 69 (see below for definitions)
• Medicare fee for service is the primary payer
• There is no Medicare secondary payer (MSP)
• Beneficiary's Medicare health insurance claim (HIC) number
• Revenue code 0024 containing CMG (case-mix groups) A9999 and include the discharge date in the service date field
• All other required claim elements (National provider identifier (NPI), charges, etc.)
Condition code 04 = Information only bill
• Code indicates bill is submitted for informational purposes only. Examples include a bill submitted as a utilization report or a bill submitted for a beneficiary who is enrolled in a risk-based managed care plan, and the hospital expects to receive payment from the plan.
Condition code 69 = IME/DGME/N&A payment only
• Code indicates a request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
Revenue code 0024 = Health insurance prospective payment system (HIPPS) inpatient rehabilitation facility (IRF) prospective payment system (PPS)