We received an RTP with reason code 12206. What steps can we take to avoid this RTP?
A: You received this RTP, because the total number of covered and non-covered days on the claim is not equal to the total number of days in the statement covers “from” and “through” dates.
• The total number of days reported on the claim must match the number of days for the statement coverage period.
• Verify the number of days reported for the statement coverage “From” and “Through” dates. The statement coverage “Through” date should be counted only if the patient status is 30 (beneficiary is still a patient).
• Verify the number of covered and non-covered days reported.
• Covered and non-covered days are reported by using value codes. Please refer to the following list of value codes and descriptions.
• Value code 80 -- Covered days
The number of days covered by the primary payer as qualified by the payer
Note: Value code 80 is used to report a combined total of the beneficiary’s full days and coinsurance and lifetime reserve days, as applicable.
• Value code 81 -- Non-covered days
Days of care not covered by the primary payer
• Value code 82 -- Co-insurance days
The inpatient Medicare days occurring after the 60th, and before the 91st day, or inpatient SNF/Swing bed days occurring after the 20th, and before the 101st, day in a single spell of illness
• Value code 83 -- Lifetime reserve days
Under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services, available to use after 90 consecutive days of inpatient hospital services during a spell of illness
Example 1:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is not 30
Covered (value code 80) + non-covered (value code 81) days = 30
Example 2:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is 30
Covered (value code 80) + non-covered (value code 81) days = 31
Q: My claim was “returned to provider” (RTP) for reason code 12302. How can I prevent claims from being returned for this reason code?
Click here for descriptions associated with Medicare Part A reason codes. Enter a valid reason code into the box and click the submit button.
A: The total number of covered and non-covered days were either counted or reported incorrectly on the claim.
• The total number of days reported on the claim must match the number of days for the statement coverage period.
• Review your documentation and overall billing for accuracy prior to making the necessary corrections.
• Verify the number of days reported for the statement coverage “From” and “Through” dates. The statement coverage “Through” date should be counted only if the patient status is 30 (beneficiary is still a patient).
• Verify the utilization days remaining on the patient’s record.
• Verify covered and non-covered days reported.
• Revalidate the accommodation units reported with Revenue Codes 012X-021X and charges.
A: You received this RTP, because the total number of covered and non-covered days on the claim is not equal to the total number of days in the statement covers “from” and “through” dates.
• The total number of days reported on the claim must match the number of days for the statement coverage period.
• Verify the number of days reported for the statement coverage “From” and “Through” dates. The statement coverage “Through” date should be counted only if the patient status is 30 (beneficiary is still a patient).
• Verify the number of covered and non-covered days reported.
• Covered and non-covered days are reported by using value codes. Please refer to the following list of value codes and descriptions.
• Value code 80 -- Covered days
The number of days covered by the primary payer as qualified by the payer
Note: Value code 80 is used to report a combined total of the beneficiary’s full days and coinsurance and lifetime reserve days, as applicable.
• Value code 81 -- Non-covered days
Days of care not covered by the primary payer
• Value code 82 -- Co-insurance days
The inpatient Medicare days occurring after the 60th, and before the 91st day, or inpatient SNF/Swing bed days occurring after the 20th, and before the 101st, day in a single spell of illness
• Value code 83 -- Lifetime reserve days
Under Medicare, each beneficiary has a lifetime reserve of 60 additional days of inpatient hospital services, available to use after 90 consecutive days of inpatient hospital services during a spell of illness
Example 1:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is not 30
Covered (value code 80) + non-covered (value code 81) days = 30
Example 2:
Statement Coverage “From” Date: 01/01/XX
Statement Coverage “Through” Date: 01/31/XX
Patient Status is 30
Covered (value code 80) + non-covered (value code 81) days = 31
Q: My claim was “returned to provider” (RTP) for reason code 12302. How can I prevent claims from being returned for this reason code?
Click here for descriptions associated with Medicare Part A reason codes. Enter a valid reason code into the box and click the submit button.
A: The total number of covered and non-covered days were either counted or reported incorrectly on the claim.
• The total number of days reported on the claim must match the number of days for the statement coverage period.
• Review your documentation and overall billing for accuracy prior to making the necessary corrections.
• Verify the number of days reported for the statement coverage “From” and “Through” dates. The statement coverage “Through” date should be counted only if the patient status is 30 (beneficiary is still a patient).
• Verify the utilization days remaining on the patient’s record.
• Verify covered and non-covered days reported.
• Revalidate the accommodation units reported with Revenue Codes 012X-021X and charges.
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