Provider-level adjustments basics - FB, WO, withholding, Internal Revenue service

Locating PLBs

• Provider-level adjustments can increase or decrease the transaction payment amount.

• Adjustment codes are located in PLB03-1, PLB05-1, PLB07-1, PLB09-1, PLB11-1 and PLB13-1.

• The PLB is not always associated with a specific claim in the 835, but must be used to balance the transaction.

• Use the Reference ID to identify the claim. Exceptions are the FB, IR, J1, L6 and CS adjustment codes (when used for provider write-off only).



The most commonly used 835 adjustment codes

The following pages explain the most commonly used PLB codes (FB, WO, 72, IR, J1, L6 and CS) and provide details of the data found in corresponding Reference ID fields.


Forward Balance (FB) 

Overpayment recovery (WO) 

Authorized Return (72) 

Internal Revenue Service 

Withholding 

Non-Reimbursable (J1) 

Interest Owed (L6) 

Adjustment (CS) 

Note:

UnitedHealthcare has two claims processing systems that will be referenced throughout this document:

1. Our Commercial claim platform is used for the majority of our business, including most commercial products and select Medica claims.

2. Our Medicare Solutions claim platform is used for Medicare Advantage products (formerly called SecureHorizons and MedicareComplete from SecureHorizons) and Evercare. Additionally, select OptumHealth Behavioral Solutions (“Optum”) and select Medica claims are processed on this platform.



Adjustment Code Reference ID

Forward Balance (FB)

• Used to reflect a balance being moved forward to a future remit or a balance that is brought forward from a prior remit.

• When a balance is moving forward to a future remit, the PLB FB contains the TRN02 (check or Electronic Funds Transfer [EFT] trace number) from the current 835 transaction.

• When a balance has been brought forward from a prior remit, the PLB FB contains the TRN02 (check or EFT trace number) that was the Reference ID in the prior remit.

Commercial and Medicare Solutions platform information and posting tips

Medicare Solutions platform note: Forward Balance is only used for select government business (SecureHorizons®, MedicareComplete® from SecureHorizons, or Evercare® by UnitedHealthcare Medicare and Retirement).

• Use the dollar amount in the PLB to balance the 835 transaction.

• A negative value represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice.

• The PLB FB is used to move a negative balance from a current 835 transaction into a future 835 transaction. Typically, this happens when we report an overpayment and there aren’t sufficient funds to recoup the entire overpayment amount.

• Forward Balance is tracked at the transaction level and is not claim-specific.




Adjustment Code Reference ID

Overpayment Recovery (WO)

• Used when a previous overpayment is recouped from the provider of service.

• Used when a reversal and corrected claim are not reported in the same transaction. WO prevents the prior claim payment from being deducted from the transaction.

• Used to offset the PLB 72.

• Used when a reversal and corrected claim are reported and the overpayment is not immediately recouped. WO prevents the prior claim payment from being deducted from the transaction.

• The Reference ID for the PLB WO contains the beginning date of service from the claim and the patient account number.

• When reporting a voided check, the Reference ID in the PLB WO is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund. We report a reversal to the original claim and a corrected claim in the 835. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the amount as a negative value in the PLB WO.

• If the reversal and corrected claim are not reported in the same 835 transaction, the 835 transaction that contains the reversal claim reports a negative value in the PLB WO. The 835 transaction that contains the corrected claim reports a positive value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• If a refund is not received within the timeframe requested in the letter, UnitedHealthcare recoups the money and reports this using the WO adjustment code. The 835 transaction that contains the overpayment recovery reduction will report a positive value in the PLB WO.



Underpayments

• Used to balance the 835 transaction when the reversal and corrected claims are not reported in the same 835 transaction and prior payment is not being recouped. The 835 transaction that contains the reversal claim will report a negative value in the PLB WO. The 835 transaction that contains the corrected claim will report a positive value in the PLB WO.

• When the reversal and corrected claim are reported in the same 835 transaction, no PLB is reported.
Provider refund check reporting

• When a refund check is received, the amount of the refund is reported as a positive value in the PLB WO and a negative value in the PLB 72.



Voided checks

When a check is voided, the amount of the voided check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

Provider refund check reporting

• When a provider’s refund check is received, the amount of the check is reported as a positive value in the PLB WO and a negative value in the PLB 72.

Voided checks

• When our check is voided, the amount of the check is reported as a positive value in the PLB WO and a negative value in the  PLB 72. The Reference ID in the PLB WO will contain the voided check number.

Overpayment Reduction (Non-Medicare Advantage products)

When we identify a claim overpayment, we report a reversal to the original claim and a corrected claim if there are sufficient funds from other claim payments to recover the amount of the overpayment. If sufficient funds are not available, we handle the overpayment with a manual recovery process after a certain amount of time.

Overpayment Reduction (specific to Medicare Advantage products and plans carrying the Medicare Solutions or Evercare®name)

Overpayments

• When we identify a claim overpayment, we send a letter requesting a refund and report a reversal to the original claim and a corrected claim. Because funds aren’t being immediately recouped, the amount of the overpayment is offset by reporting the
overpayment amount as a negative value in the PLB WO.

Overpayment Recovery Reduction

• Used when a previous overpayment is recouped from the provider of service.

• UnitedHealthcare sends a letter requesting a refund. If the refund is not received within the requested timeframe,

UnitedHealthcare recoups the money. The overpayment reduction is reported as a positive value in the PLB WO.





Adjustment Code Reference ID

Authorized Return (72)

• Used to report the dollar amount returned by the provider of service for a previous overpayment.

• Used to report a voided check.

The Reference ID in the PLB 72 contains the beginning date of service from the claim and the patient account number (Commercial and Medicare Solutions platforms).

When reporting a voided check, the Reference ID in the PLB 72 is the voided check number (Medicare Solutions platform).

Commercial platform information and posting tips

Use the dollar amount in the PLB to balance the transaction.

For Solicited Refunds:

• The reversal and corrected claim were reported in a prior 835 and included a PLB WO so that overpayment funds weren’t recouped.

• Once the refund is received by UnitedHealthcare, the refund amount is noted as a negative value in the PLB segment with the 72 Adjustment Reason Code.

• A PLB WO with the amount of the refund is then created to offset the PLB 72 and balance the 835 transaction. The PLB WO will contain a positive value.

For Unsolicited Refunds:

• When we post a refund, we usually enter both a reversal of payment and a corrected claim so that the reversal and PLB 72 will be in the same 835 file.

• If the refund does not cover the entire overpayment amount, the 835 will also contain a PLB WO for the amount remaining to be refunded. The PLB WO will contain a negative value.

Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• When we receive a refund, we note the refund amount as a negative value in the PLB segment with the 72 Adjustment
Reason Code.

• When a physician returns a UnitedHealthcare check, the voided check amount is noted as a negative value in the PLB 72.

The Reference ID in the PLB 72 will contain the voided check number.

• A PLB WO with the amount of the refund or voided check is reported as a positive value to offset the PLB 72 and balances the 835 transaction. We do not report a reversal and corrected claim in the 835 transaction.



Adjustment Code Reference ID

Internal Revenue Service Withholding (IR)

• Used for IRS tax withholding.

• The Reference ID in the PLB IR contains the beginning date of service from the applicable claim and the patient account number (Commercial platform).

• The Reference ID in the PLB IR contains the comment ‘IRS Withhold for TIN XXXXXXXXX’ (Medicare Solutions platform).

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The payment amount sent to the IRS is reported in the PLB segment with an IR Adjustment Reason Code and a positive dollar amount.

• The claim will be in the same 835 as the PLB. Post the claim payment amount(s) to your patient accounts, but note that you will not physically receive funds for the payment amounts.




Adjustment Code Reference ID

Non-Reimbursable (J1)

• Used when the service provider is also the employer group and they request that monies be applied towards the Group
Medical Plan coverage premium instead of the claim.

The Reference ID in the PLB J1 contains the comment “Suppressed Payment Arrangement.”

Commercial platform information and posting tips (does not apply to Medicare Solutions platform) Use the dollar amount in the PLB to balance the 835 transaction.

• J1 will be in the same 835 as the claim.

• Post amounts to your patient accounts, but note that you will not physically receive funds for the claim payments.

• The dollar amount of the suppressed payment for the PLB J1 will be a positive value.




Adjustment Code Reference ID

Interest Owed (L6)

• Used to report interest paid on claims.

No Reference ID is included with the PLB L6. The amount reported is a sum of the AMT*I segments.

Commercial and Medicare Solutions platform information and posting tips

Use the dollar amount in the PLB to balance the 835 transaction.

• The amount of interest paid is reported in the PLB L6 as a negative amount and adds to the check total. The claim is in the same 835 transaction.

• To associate interest amounts with corresponding claims, use the AMT*1 segments at the claim level.

• The claim will contain an AMT segment in loop 2100 with an “I” (Interest) Amount Qualifier Code in the AMT01 and the interest amount in the AMT02.




Adjustment Code Reference ID

Adjustment (CS)

• Used to report the reissued payment amount for a lost check; or to

• Reduce a PLB FB balance if we write off an amount a provider owes; or to

• Reduce a PLB FB balance when the overpayment amount has been reduced.

• When reporting repayment for a lost check, the Reference ID contains the check number of the lost check (Medicare Solutions platform only).

• When reducing a prior PLB FB balance, the Reference ID is “Payer Write-Off” (Commercial platform).

• When a PLB FB balance is reduced due to claims reprocessing, the Reference ID will contain the beginning date of service and Patient Account Number of the associated claim (Commercial platform).

Commercial platform information and posting tips

Use the amount in the PLB to balance the transaction.

• A PLB FB balance was created on a prior 835 transaction. This was likely due to a recovery (PLB WO) being reported when there weren’t sufficient funds to recoup the entire overpayment amount. (See PLB FB Adjustment Code for additional information.)

• When a PLB FB remains uncollected and we decide not to recoup all or part of the remaining amount due, the amount written off will be reported in the 835 with a PLB CS.

• The 835 transaction will include the PLB FB and the balance amount from the prior 835 and a PLB CS for the amount of payer write-off. The PLB FB will report a positive amount (indicating an amount is brought forward from a prior 835) and the PLB CS will report a negative amount.

Medicare Solutions platform information and posting tips

Use the amount in the PLB to balance the transaction.

• The amount of the lost check is reported in the PLB CS as a negative value.

• The claim associated with the lost check will not be reported in an 835 transaction again. Only the payment will be reissued.

CONTENT OF SERVICE

Content of service refers to specific services and/or procedures that are considered to be an integral part of previous or concomitant services or procedures to the extent that separate reimbursement is not recognized. Not all content of service issues are identified in the policies and procedures. BCBSKS staff may identify and classify specific coding and nomenclature issues as they arise. Examples of services that can be considered content of service are:

• Examination of the patient.

• History of illness and/or review of patient records.

• Evaluation of tests or studies (i.e., radiology or pathology).

• Any entries into the patient's records.

• Evaluation of reports of tests or studies earlier referred to another physician for an opinion and subsequently returned for use in the office visit being conducted.

• Advice or information provided during or in association with the visit.

• Case management.

• The prescription of any medicinals, home supplies or equipment during or as a result of the visit.

• The application or the re-application of any standard dressing during a visit.

• Therapeutic, prophylactic, or diagnostic injection administration provided on the same day as an office visit, home visit, or nursing home visit.

• Additional charges beyond the regular charge for services requested after office hours, holidays or in an emergency situation.

• Items of office overhead such as malpractice insurance, telephones, personnel, supplies, cleaning, disinfectants, photographs, equipment sterilization, etc.

• Telephone calls and web-based correspondence are content of service when billed with another service on the same day. Such services are not covered if billed separately and the only service rendered on that day.

• Anesthesia provided in an office setting is considered content of service and not reimbursed separately. The provider cannot require the patient to sign a waiver or bill the patient for this service.

Some content of service issues related to specific services and/or procedures are identified throughout the policy and procedure documents.

NOTE: All-inclusive procedure codes must be used when available.

UTILIZATION REVIEW AND MEDICAL NECESSITY

The contracting provider agreement requires providers to cooperate in utilization review and medical necessity determinations. Utilization review is the process of determining the appropriateness of services rendered to and payments made on behalf of members. Appropriateness of service and payment determinations consist of the following activities:


A. MEDICAL NEED FOR SERVICES RENDERED

Medical necessity policy applies to all services rendered to BCBSKS members and includes any services or supplies used to diagnose and/or treat illness or injury. The service should be widely accepted by a peer group of practicing providers, based on scientific criteria and determined to be reasonably safe. Health care professionals should discuss all appropriate treatment alternatives available to patients regardless of benefit coverage limitations. To be determined medically necessary, the service must be consistent with the diagnosis and treatment of the condition; be in accordance with standards of good health care practice; and not be for the convenience of the patient or provider. The following procedures/equipment would be subject to medical necessity and utilization review:

1. Established procedures/equipment of questionable current usefulness in the treatment of a specific condition(s).

2. Procedures/equipment which tend to be redundant when performed/supplied in combination with other procedures/equipment; or procedures/equipment which are unlikely to provide additional medical benefits, or are contradicting to one another.

3. Specific procedures/equipment or patterns of care which vary significantly from a peer group.


B. PRE-ADMISSION CERTIFICATION & CONCURRENT REVIEW

Before admitting a member to a hospital for elective (non-obstetrical, non-life threatening) inpatient care, medical information will need to be supplied to BCBSKS in order to certify medical necessity. A length of stay will be assigned at the time of pre-certification and will be subject to concurrent review. Concurrent review is the process of obtaining current medical information to review for the medical necessity of a requested extension to the length of stay or course of treatment. For the most accurate and complete information, all pre-admission certification should be validated through the BCBSKS provider portal (Availity®).


BCBSKS pre-admission certification and concurrent review activity are conducted in compliance with URAC guidelines. This includes the availability of either the expedited or standard appeal to services denied for medical necessity during the pre-admission certification and concurrent review processes. To initiate an appeal (phone or fax), you must have complete information since the time frame begins with the appeal request. These appeal options are only available prior to claim submission and are subject to time frames as established by BCBSKS, Department of Labor, and URAC. All pre-admission certification appeals for professional and hospital services will be reviewed concomitantly.


C. OUTPATIENT PRE-CERTIFICATION/PRIOR AUTHORIZATION

Under certain circumstances, pre-certification/prior authorization may be required for outpatient services/procedures. BCBSKS will notify contracting providers at least 30 days in advance of such requirement.


Pre-certification/prior authorization may also be required for other outpatient services such as home medical equipment and case management, including those services specified by employers, and outpatient procedures which necessitate a greater level of facility care than is usually needed.

Following provider notification, continued failure to complete pre-certification/prior authorization activities will result in a 50 percent Maximum Allowable Payment (MAP) reduction up to $200 with the member held harmless. Compliance audits will take place on a post-payment basis, which may result in refunds.


D. CASE MANAGEMENT

Case management is a process that identifies and coordinates alternative treatment plans to enhance care through effective administration of available health care resources in the most cost-efficient manner. The process is accomplished through the development of a treatment plan by the patient or legal representative, the physician, other health care providers, and the BCBSKS case manager.


E. PREPAYMENT AND DATA ANALYSIS

BCBSKS will identify any trends or patterns of patient care, i.e., through data analysis, which appear inconsistent with overall patterns or trends. Prepayment review will be implemented if attempts to work with the provider have failed to resolve the issue. Specific utilization guidelines may be applied to individual prepay members. Prepayment review means all claims will be reviewed before payment and records will be required.


F. APPROPRIATE PLACE OF SERVICE

The provider agrees to use (to the extent possible) those inpatient, extended care, ancillary services and other health facilities and health professionals which have contracted with BCBSKS. Providers agree to render services to members in the most appropriate and economical setting consistent with the member’s diagnosis, treatment needs, and medical condition.

Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally requesting contract cancellation. In the event members request referrals to non-contracting providers, providers should have patients sign a statement acknowledging full understanding of the non-contracting referral and the patient’s financial responsibilities. The statement should be filed in the patient’s chart.


G. RESOLUTION OF PROBLEMS

Providers agree to work with BCBSKS and other providers of care in the resolution of any utilization or medical review problems that may be identified. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally contract cancellation.


H. MEDICAL NECESSITY/UTILIZATION REVIEW DENIALS

Occasionally BCBSKS does not consider an item or service to be medically necessary. In such situations the item or service becomes a provider write-off. In the few situations where services are known to be denied as not medically necessary (including deluxe items) and the patient insists on the services, the provider must obtain a patient waiver in advance of the services being rendered. (See Section X. WAIVER FORM)
Failure to discuss the above with the patient in advance, document this in the medical record, and obtain the waiver will result in a provider write-off.

NOTE: BCBSKS members are not to be billed for services determined to be unnecessary through the medical and utilization review process, per the Contracting Provider Agreements.

Appeal POLICIES AND PROCEDURES

Appeals as the Member’s Authorized Representative: Appeals that you can make as the member’s authorized representative according to the terms of the member’s contract are claims for which the member is financially responsible. When you act as the member’s authorized representative, you are not separately entitled to any appeals pursuant to this Contracting Provider Agreement.


 Appeals Pursuant to Contracting Provider’s Agreement

First Level: Written notification of disagreement highlighting specific points for reconsideration of a claim denied not medically necessary shall be provided to BCBSKS within 60 days from the date of the retrospective review determination. This notice shall be considered an initial appeal and be forwarded with all pertinent medical records to BCBSKS Customer Service. Medical records submitted with the request for initial appeal will be referred to the appropriate consultant and a determination will be rendered. This decision will be binding unless the provider files a second-level appeal within 60 days of notification of such decision.


Second Level: Forward a written request for the second-level appeal to BCBSKS customer service within 60 days following the first-level appeal denial notification. The second and final appeal determination shall be made by a physician or clinical peer. The contracting provider agrees to abide by the second-level appeal determination.


All appeal decisions under this agreement must be provided within 60 days of receipt of the provider's request. Any appeals decision not provided within the aforementioned time frames shall be considered as decisions made in favor of the provider and claim payments will be adjusted accordingly.


A contracting provider agrees to accept the determination made at each level or to appeal the determination at the next step of the appeals process. If throughout the appeals process the decision on the claim changes in the provider's favor, an additional payment will be made. However, a refund will be requested if the decision reverses a previous determination (either partially or totally).

The result of the appeals process shall be binding on the provider and BCBSKS subject only to the provision for binding arbitration previously stated herein.

Billing rules for autologous, split unit, Irradiation blood productions - 86891, cpt P9010, P9057

 Billing for Autologous Blood (Including Salvaged Blood) and Directed Donor Blood


In general, when autologous (predeposited or obtained through intra- or postoperative salvage) or directed-donor transfusion is performed, OPPS providers should bill for the transfusion service and the number of units of the appropriate HCPCS code that describes the blood product. Payment for the product is intended to cover the costs associated with providing the autologous or directed donor blood product service (e.g., collection, processing, transportation, and storage). OPPS providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.

When an autologous blood product is collected but not transfused, OPPS providers should bill Procedure  86890 (autologous blood or component, collection, processing, and storage; predeposited) or 86891(autologous blood or component, collection, processing, and storage; intra- or postoperative salvage) and the number of units collected but not transfused. Procedure  86890 and 86891 are intended to provide payment for the additional resources needed to provide these services, which are not captured when a blood product HCPCS code is not billed. Because billing 86890 or 86891 is only indicated when autologous blood is collected but not transfused, the OPPS provider should bill 86890 or 86891 on the date when the OPPS provider is certain the blood will not be transfused (i.e., date of a procedure or date of outpatient discharge), rather than on the date of the product’s collection or receipt from the supplier.

When a directed donor blood product is collected but not transfused to the initial targeted recipient or to any other patient, refer to the section 231.7 titled “Billing for Unused Blood.”



Billing for Split Unit of Blood


HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split and some portion of the unit is transfused to one patient and the other portions are transfused to other patients or to the same patient at other times. When a patient receives a transfusion of a split unit of blood or blood product, OPPS providers should bill P9011 for the blood product transfused, as well as Procedure  86985 (Splitting, blood products) for each splitting procedure performed to prepare the blood product for a specific patient.

Providers should bill split units of packed red cells and whole blood using Revenue Code 389 (Other blood), and should not use Revenue Codes 381 (Packed red cells) or 382 (Whole blood). Providers should bill split units of other blood products using the applicable revenue codes for the blood product type, such as 383 (Plasma) or 384 (Platelets), rather than 389. Reporting revenue codes according to these specifications will ensure the Medicare beneficiary's blood deductible is applied correctly.

EXAMPLE: OPPS provider splits off a 100cc aliquot from a 250 cc unit of leukocyte-reduced red blood cells for a transfusion to Patient X. The hospital then splits off an 80cc aliquot of the remaining unit for a transfusion to Patient Y. At a later time, the remaining 70cc from the unit is transfused to Patient Z.

In billing for the services for Patient X and Patient Y, the OPPS provider should report the charges by billing P9011 and 86985 in addition to the Procedure  code for the transfusion service, because a specific splitting service was required to prepare a split unit for transfusion to each of those patients. However, the OPPS provider should report only P9011 and the Procedure  code for the transfusion service for Patient Z because no additional splitting was necessary to prepare the split unit for transfusion to Patient Z. The OPPS provider should bill Revenue Code 0389 for each split unit of the leukocyte-reduced red blood cells that was transfused.


Billing for Irradiation of Blood Products

In situations where a beneficiary receives a medically reasonable and necessary transfusion of an irradiated blood product, an OPPS provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the Procedure  code for the transfusion. If a specific HCPCS code for the irradiated blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with Procedure  code 86945 (irradiation of blood product, each unit).

EXAMPLE: If an OPPS provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional Procedure  code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040.



 Billing for Frozen and Thawed Blood and Blood Products


In situations where a beneficiary receives a transfusion of frozen blood or a blood product which has been frozen and thawed for the patient prior to the transfusion, an OPPS provider may bill the specific HCPCS code which describes the frozen and thawed product, if a specific code exists, in addition to the Procedure  code for the transfusion.. If a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with Procedure  codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code.

EXAMPLE: If an OPPS provider transfuses the product described by P9057 (red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill additional Procedure  codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for P9057.

If a blood product has been frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion of the blood product, the OPPS provider may bill the patient for the Procedure  code that describes the freezing and/or thawing services specifically provided for the patient. Similar to billing for autologous blood collection when blood is not transfused, the OPPS provider should bill the freezing and/or thawing services on the date when the OPPS provider is certain the blood product will not be transfused (e.g., date of a procedure or date of outpatient discharge), rather than on the date of the freezing and/or thawing services.

The following chart of blood and blood products indicates whether providers should bill separately for freezing and thawing using the available Procedure  codes.



HCPCS/Procedure                Short Descriptor             Billing of Freezing/Thawing

P9010

Whole blood for transfusion

Freezing and thawing are separately billable

P9011

Blood split unit

Freezing and thawing are separately billable

P9012

Cryoprecipitate each unit

Freezing and thawing codes not separately billable

P9016

RBC leukocytes reduced

Alternative P-code for frozen/thawed product available

P9017

Plasma 1 donor frz w/in 8 hr

Freezing and thawing codes not separately billable

P9019

Platelets, each unit

Freezing and thawing are separately billable

P9020

Plaelet rich plasma unit

Freezing and thawing are separately billable

P9021

Red blood cells unit

Alternative P-code for frozen/thawed product available

P9022

Washed red blood cells unit

Freezing and thawing are separately billable

P9023

Frozen plasma, pooled, sd

Freezing and thawing codes not separately billable

P9031

Platelets leukocytes reduced

Freezing and thawing are separately billable

P9032

Platelets, irradiated

Freezing and thawing are separately billable

P9033

Platelets leukoreduced irrad

Freezing and thawing are separately billable

P9034

Platelets, pheresis

Freezing and thawing are separately billable

P9035

Platelet pheres leukoreduced

Freezing and thawing are separately billable

P9036

Platelet pheresis irradiated

Freezing and thawing are separately billable

P9037

Plate pheres leukoredu irrad

Freezing and thawing are separately billable

P9038

RBC irradiated

Freezing and thawing are separately billable

P9039

RBC deglycerolized

Freezing and thawing codes not separately billable

P9040

RBC leukoreduced irradiated

Alternative P-code for frozen/thawed product available

P9043

Plasma protein fract,5%,50ml

Concept not applicable

P9044

Cryoprecipitate reduced plasma

Freezing and thawing codes not separately billable

P9048

Plasmaprotein fract,5%,250ml

Concept not applicable

P9050

Granulocytes, pheresis unit

Concept not applicable

P9051

Blood, l/r, cmv-neg

Freezing and thawing are separately billable

P9052

Platelets, hla-m, l/r, unit

Freezing and thawing are separately billable

P9053

Plt, pher, l/r cmv-neg, irr

Freezing and thawing are separately billable

P9054

Blood, l/r, froz/degly/wash

Freezing and thawing codes not separately billable

P9055

Plt, aph/pher, l/r, cmv-neg

Freezing and thawing are separately billable

P9056

Blood, l/r, irradiated

Freezing and thawing are separately billable

P9057

RBC, frz/deg/wsh, l/r, irrad

Freezing and thawing codes not separately billable

P9058

RBC, l/r, cmv-neg, irrad

Freezing and thawing are separately billable


P9059

Plasma, frz between 8-24hour

Freezing and thawing codes not separately billable

P9060

Fr frz plasma donor retested

Freezing and thawing codes not separately billable



To report charges for transfusion services, OPPS providers should bill the appropriate Procedure  code for the specific transfusion service provided under Revenue Code 391 (Blood Administration). Transfusion services codes are billed on a per service basis, and not by the number of units of blood product transfused. For payment, a blood product HCPCS code is required when billing a transfusion service code. A transfusion APC will be paid to the OPPS provider for transfusing blood products once per day, regardless of the number of units or different types of blood products transfused.


 Billing for Pheresis and Apheresis Services


Apheresis/pheresis services are billed on a per visit basis and not on a per unit basis. OPPS providers should report the charge for an Evaluation and Management (E&M) visit only if there is a separately identifiable E&M service performed which extends beyond the evaluation and management portion of a typical apheresis/pheresis service. If the OPPS provider is billing an E&M visit code in addition to the apheresis/pheresis service, it may be appropriate to use the HCPCS modifier -25.


 Billing for Autologous Stem Cell Transplants

The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished. It shows charges for the actual transplant, described by the appropriate ICD procedure or Procedure  codes in Revenue Center 0362 (Operating Room Services; Organ Transplant, Other than Kidney) or another appropriate cost center.

The Procedure  codes describing autologous stem cell harvesting procedures may be billed and are separately payable under the Outpatient Prospective Payment System (OPPS) when provided in the hospital outpatient setting of care. Autologous harvesting procedures are distinct from the acquisition services described in Pub. 100-04, Chapter 3, §90.3.1 and §231.11 of this chapter for allogeneic stem cell transplants, which include services provided when stem cells are obtained from a donor and not from the patient undergoing the stem cell transplant.

The Procedure  codes describing autologous stem cell processing procedures also may be billed and are separately payable under the OPPS when provided to hospital outpatients.

BCBS claim appeal overview - Standard, Expedite and dispute

MEDICAL APPEALS

Medical Appeals are clinical in nature and involve adverse benefit determinations of not medically necessary or investigational. All other Appeals are considered Administrative Appeals and are handled by the Administrative Appeals and Grievance Department. The process and contact information for this department is located elsewhere in this document.

We recognize that disputes may arise between members (member’s provider) and Blue Cross regarding covered services. An appeal is a written request from the member or authorized representative to change a prior decision that Blue Cross has made about covered services. Examples of issues that qualify as appeals include denied authorizations, claims based on adverse determinations of medical necessity or investigational denials, and be nefit determinations. A rescission of coverage is also eligible for an appeal.

The Member has the right to appoint an authorized representative to speak on their behalf in their Appeals. An authorized representative is a person to whom the Member has given written consent to represent the Member in an internal or external review of a denial. The authorized representative may be the Member’s treating Provider, if the Member appoints the Provider in writing.

The Member, their authorized representative, or a Provider authorized to act on the Member’s behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Requests submitted to Us after one hundred eighty (180) days of Our initial determination will not be considered.

Member appeals processes vary due to variations in state and federal laws. We will apply the law that governs the benefits purchased by the member or the member’s employer. In some instances this is state law, and in others, it is federal law. The member’s contract or certificate describes the appeals processes applicable to the member. We will follow the language in the member’s contract or certificate, should there be any variance between that language and what is printed below.

Due to variations between federal and state laws, appeals for ERISA members are handled differently from non-ERISA member appeals. There are some plans that are not governed by either the state laws or the ERISA laws. Examples are some plans for whom we provide administrative services only and the Federal Employee Program. For these members, we will follow the appeals processes stated in their member contracts. The majority of appeals should fall within the ERISA or non-ERISA (state) processes. If members are unsure which process applies to them, they should contact their employer, Plan Administrator, Plan Sponsor or Blue Cross at 1-800-599-2583 or 225-291-5370. Members and providers are encouraged to provide Blue Cross with all available information and documentation at the time of the appeal request to help Us completely evaluate the appeal.


Louisiana laws apply to individual contracts of insurance, employer insurance plans that are not governed by ERISA, and non-federal government insurance plans. Blue Cross generally refers to these processes  as “Non-ERISA” processes. We will follow internal and external laws set out in La. R.S. 22:2391 et seq. and applicable regulations for these types of plans. We will follow the appeal rules for ERISA plans as set out in 29 CFR 2560 et seq. If the laws that affect appeals for any type of plan change, we will revise our process to maintain compliance.

We will investigate the Member’s concerns. If we change Our original decision at the first level, We will process the Member’s Claim and notify the Member and all appropriate Providers. If the original determination on the Member’s Claim is upheld, We will notify the Member and all appropriate Providers of the decision. Notice of the Administrative Appeal decision will be sent in writing within thirty (30) calendar days of our receipt of the member’s request; unless it is mutually agreed that an extension of the time is warranted.

Both federal and state Medical Appeals processes include two levels of review; an internal level and an external level.

The internal level of review will be conducted by Persons not involved in previous decisions regarding the member’s claim will decide all Appeals. A physician or other health care professional; in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review and who is not subordinate to any previous decision-maker on the member’s claim, will review medical necessity appeals.

External level of review can be requested by the member, their authorized representative, or a provider authorized to act on the member’s behalf, who must submit a written request to Appeal within one hundred twenty (120) days following the member’s receipt of an internal appeal adverse benefit determination. Request submitted to us after one hundred twenty (120) days of Our internal appeal determination will not be considered. Please note that for those plans subject to Louisiana state law, the External Review request form provided with an internal appeal denial notice MUST be signed by the member and returned with any request for External Review.

The external level of review will be conducted by a non-affiliated Independent Review Organization (IRO). We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us.

The external review will be completed within forty-five (45) days of Our receipt of the request, and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.

Expedited Medical appeals requests are available in cases where review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the member may experience pain that cannot be adequately controlled while awaiting a standard internal appeal decision. In these cases, we will make a decision no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.


An Expedited Appeal is a request concerning an Admission, availability of care, continued stay, or health care service for a covered person who is requesting Emergency services or has received Emergency services, but has not been discharged from a facility. Expedited Appeals are not provided for review of services previously rendered. An Expedited Appeal shall be made available to, and may be initiated by the covered person; the covered person’s authorized representative, or the Provider acting on behalf of the covered person.

Standard Administrative Appeal

 First Level Administrative Process

Administrative Appeals involve contractual issues other than Medical Necessity or Investigational denials and those denials that do not require medical judgment.

If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to:

Medical Benefits:
Blue Cross and Blue Shield of Louisiana
Appeals and Grievance Unit
P. O. Box 98045
Baton Rouge, LA 70898-9045


Pediatric Dental Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
Dental Customer Service
P. O. Box 69420
Harrisburg, PA 17106-9420


Pediatric Vision Care Benefits: (applicable to Non-Grandfathered Individual and Small Group ONLY)
Blue Cross and Blue Shield of Louisiana
c/o Davis Vision
P. O. Box 791
Latham, NY 12110


Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be considered.

We will investigate the Member’s concerns. If We change Our original decision at the Appeal level, We will process the Member’s Claim and notify the Member and all appropriate Providers, in writing, of the first level Appeal decision. If the Member’s Claim is denied on Appeal, We will notify the Member and all appropriate Providers, in writing, of Our decision within thirty (30) calendar days of the Member’s  request; unless We mutually agree that an extension of the time is warranted. At that time, We will inform the Member of the right to begin the second level Appeal process, if applicable.

Second Level Administrative Process (If Applicable)

Within sixty (60) calendar days of the date of Our first level Appeal decision, a Member who is not satisfied with the decision may initiate, with assistance from the Customer Service Unit, if necessary, the second level of Appeal process. Requests submitted to Us after sixty (60) days of the denial will not be considered.

A Member Appeals Committee not involved in any previous denial will review all second level Appeals. The Committee’s decision is final and binding as to any administrative Appeal and will be mailed to the Member within five (5) days of the Committee meeting.

 Standard Medical Appeal

Internal Process

Medical Appeals involving a denial or partial denial based on Medical Necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational. If the Member is not satisfied with Our denial of services, the Member, their authorized representative, or a Provider acting on their behalf, must submit a written request to Appeal within one hundred eighty (180) days following the Member’s receipt of an initial adverse Benefit determination. Appeals should be submitted in writing to or fax to:

Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


Note: Requests submitted to Blue Cross after one hundred eighty (180) days of the denial will not be  considered.

We will investigate the member’s concerns. All Appeals of Medical Necessity denials will be reviewed by a physician or other health care professional in the same or an appropriate specialty that typically manages the medical condition, procedure, or treatment under review. If our initial denial is overturned on the Member’s Medical Necessity Appeal, We will process the claim and will notify the Member and all appropriate Providers, in writing, of the Internal Appeal decision. If our initial denial is upheld, We  will notify the Member and all appropriate Providers, in writing, of our decision and advise the Member of their right to request an External Appeal. The decision will be mailed within thirty (30) days of the member’s request, unless the member or their authorized representative and We mutually agree that an extension of the time is warranted. At that time, We will inform the member of their right to begin the External Appeal process if the claim meets the criteria.


External Process

If the Member still disagrees with our determination on their Claim following the internal review process, the Member or their authorized representative may request an External Appeal conducted by a non-affiliated Independent Review Organization (IRO). The Member must send their written request for an external Appeal, within one hundred twenty (120) days* of receipt of the Internal Appeal decision.The Member must grant permission  for the request of an External Review by completing and submitting at the time of External Appeal request the form "I want to ask for an External Appeal." Any external review requested without the required form will not be considered.

Blue Cross and Blue Shield of Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837

HMO Louisiana, Inc.
Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax 225-298-1837

We will provide the IRO all pertinent information necessary to conduct the Appeal. The IRO decision will be considered a final and binding decision on both the Member and Us. The external review will be completed within forty-five (45) days of Our receipt of the request and the IRO will notify the Member or their authorized representative and all appropriate Providers of its decision.

* Requests submitted to us after one hundred twenty (120) days of receipt of the internal Appeal decision will not be considered.


Expedited Appeals

Internal Process

We provide an Expedited Appeal process for review of an Adverse Determination involving a situation where the time frame of the standard Appeal would seriously jeopardize the Member’s life, health or ability to regain maximum function. It includes a situation where, in the opinion of the treating physician, the Member may experience pain that cannot be adequately controlled while awaiting a standard Internal Appeal decision.


The Expedited Appeal process allows for expedited appeal decisions no later than seventy-two (72) hours of our receipt of an Expedited Appeal request that meets the criteria for Expedited Appeal.

An Expedited Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment.   Expedited Appeals are not provided for services previously rendered.

Blue Cross and Blue Shield of Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022
Fax: 225-298-1837


HMO Louisiana, Inc.
Expedited Appeal - Medical Appeals
P. O. Box 98022
Baton Rouge, LA 70898-9022

In any case where the Expedited Internal Appeal process does not resolve a difference of opinion between Us and the covered person or the Provider acting on behalf of the covered person, the Appeal may be elevated to an Expedited External Appeal.


External Process

An Expedited External Appeal of an adverse decision is available when requested by the Member, their authorized representative or a provider acting on behalf of a member.

An Expedited External Appeal is a request for immediate review of an initial non-certification determination concerning an admission, availability of care, continued stay, or health care service for a covered person or his authorized representative who is requesting emergency services or has received emergency services but has not been discharged from a facility or if waiting for the standard Appeal 30 day process could seriously jeopardize the member’s life, health or ability to regain maximum function or in the treating physician’s opinion, the patient would be subjected to severe pain without care or treatment.

Expedited External Appeals are not provided for review of services previously rendered. An Expedited External Appeal is also available if the Adverse Determination involves a denial of coverage based on a determination that the recommended or requested health care service or
treatment is deemed Investigational; and the covered person’s treating Physician certifies in writing  that the recommended or requested health care service or treatment that is the subject of the Adverse Determination would be significantly less effective if not promptly initiated. The request may be simultaneously filed with a request for an expedited internal review, since the Independent Review Organization assigned to conduct the expedited external review will determine whether the request is eligible for an external review at the time of receipt.


We will forward all pertinent information for Expedited External Appeal requests to the IRO so the review may be completed within seventy-two (72) hours of receipt.

All external review decisions are binding on Us and You for purposes of determining coverage under a health Contract. This Appeals process shall constitute Your sole recourse in disputes concerning determinations of whether a health service or item is or was Medically Necessary, except to the extent that other remedies are available under state or federal law.


Please Note:

Although submission of additional information is not required at the time an appeal request is requested, an explanation and/or supporting documentation for an appeal is recommended.


Dispute Resolution

Blue Cross has established a general dispute resolution process to resolve any problems and disputes concerning Blue Cross’ right of offset or recoupment. To initiate the general dispute resolution process, providers should send a written notice with a brief description of their dispute to:


Blue Cross and Blue Shield of Louisiana
Provider Dispute
P.O. Box 98021
Baton Rouge, LA 70898-9021

Within sixty (60) calendar days of our receipt of the provider’s notice, Blue Cross and the provider will assign appropriate staff members who are to arrange to discuss and seek resolution of the dispute, consistent with the terms of the provider’s agreement with Blue Cross. Any and all dispute resolution procedures are to be conducted only between Blue Cross and the provider and shall not include any Blue Cross or HMO Louisiana member unless such involvement is necessary to the resolution of the dispute. Blue Cross, in its sole discretion, will determine if the member’s involvement is necessary to the resolution of the dispute.


If Blue Cross and the provider are unable to reach resolution within the initial sixty (60) day period, then management from both Blue Cross and the provider, who were not involved in the initial discussion, will have an additional thirty (30) days to resolve the dispute. This time period may be extended by mutual agreement between Blue Cross and the provider. Blue Cross and the provider, as mutually agreed, may include a mediator in such discussions. Blue Cross and the provider shall share the costs of the mediation equally. In any event, if additional meetings are held and no resolution of the dispute is reached within sixty (60) days from the initial meeting, Blue Cross and the provider shall elect binding arbitration as described in the Arbitration section below in order to resolve the dispute. Blue Cross or the provider’s failure to participate in the arbitration proceedings means that they have accepted the other’s demands. If resolution of the dispute occurs, Blue Cross and the provider shall express the resolution in written form or amend the provider’s agreement to include the resolution, if appropriate.

CPT code 88175, 88155, 88164, 88165, 88150 - Cervical Cytology Value Set

Procedure  code and Description

88175 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thinlayer preparation; screening by automated system, under physician supervision



Category Inclusions Cost


Supplies Liquid based Pap test Stains and Fixatives Preparation Liquid based pap processor for automated screening, personnel, disposal of waste Evaluation Cytotechnologist and support salaries, pathologists salary Indirect Expenses Client service, record keeping, reports, liability, training, storage, occupancy and institutional overhead Total

88155 Cytopathology, slides, cervical or vaginal definitive hormonal evaluation


88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

88165 With manual screening and rescreening under physician supervision



Papanicolaou Smear

Description: The following policy addresses Blue Cross and Blue Shield of Minnesota’s (Blue Cross) billing and coverage of Papanicolaou (Pap) tests.

Definitions: A Pap test is a smear of vaginal or cervical cells obtained for cytological study.

There are several types of methods and systems of testing the smear. Codes 88142-88154, 88164-88167, 88174-88175, P3000, P3001, G0123-G0124, and G0141, G0143-G0148 are for cytopathology screening of cervical or vaginal smears.


Policy: The procedure codes, diagnosis codes, specimen collection codes and handling fee that apply to Papanicolaou smears are detailed below.

Procedure Codes

Codes 88142-88154, 88164-88167, 88174-88175, P3000, P3001, G0123-G0124, and G0141, G0143-G0148 are for cytopathology screening of cervical or vaginal smears. Submit the appropriate code to reflect the service provided.

Procedure code 88141 and 88155 are used to report physician interpretation of a cervical or vaginal specimen and should be listed in addition to the screening code chosen when the additional services are provided.

Diagnosis Codes

Routine cervical Papanicolaou smears should be reported with appropriate ICD-10-CM diagnosis codes:

Use this code… In this situation…

Z01.42 As part of a general gynecological examination

Z12.4 Without a general gynecological examination

Coding Guidelines for PAP smear

1. Determine if the test is screening or diagnostic.

2. Choose the code that best describes the method of testing, i.e. Thin Prep, Bethesda, or other.

Summary Procedure  section for cervicovaginal cytology (c/v): 88150-88154- c/v, conventional smear, “other” (non-Bethesda) reporting system 88164-88167- c/v, conventional smear, Bethesda reporting system 88142-88143- c/v, liquid-based cytology, any reporting system 88174-88175- c/v, liquid-based cytology, computer-assisted screening, any reporting system

3. Use procedure code 88199 only to indicate the service was provided with a system that is considered investigational. When services are provided by a method that is not FDA-approved, the entire service is considered non-covered.

a. Liquid based monolayer cell preparation technique is considered “investigational” when provided with systems that have not received FDA approval.

b. Do not list the pap test procedure code. List the description of the service “Investigational - (name of system,)”, in Box 19 of the HCFA 1500 form or on an attachment. This information is placed in the Narrative Record (HA0 record) for EMC submitters.

4. Liquid based prep services are no longer paid in addition to a Pap smear performed by another method, instead, they are available as another method of performing the test.


Cervical Cancer Screening Procedure Codes 88141-88143, 88147, 88148, 88150, 88152-88154, 88164-88167, 88174, 88175 HCPCS G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 UB Rev Codes 0923 HPV Procedure Codes

87620-87622 LOINC Codes

21440-3, 30167-1, 38372-9, 49896-4, 59420-0 Women 21-64 years of age with one or more Pap tests within the last 3 years OR for women 30-64 years of age, a cervical cytology and human papillomavirus (HPV) co-testing with in the last 5 years. Notation of Pap test located in progress notes MUST  include the lab results in order to meet NCQA® requirements.

Cervical cytology and human papillomavirus test must be completed four or less days apart in order to qualify for every 5 years testing.

The provider performing the Pap/pelvic/breast exam visit may submit procedure codes G0101 and Q0091.

** G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination)
** Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)


If a screening rectal exam is performed as part of the Pap/pelvic/breast exam, it is considered incidental and may not be separately reported.The laboratory performing the Pap test may bill the appropriate lab and pathology procedure code(s) for examining the Pap smear specimen (e.g. 88141-88155, 88164-88167, 88174- 88175).

Laboratory Services

Medicaid family planning service providers must document all laboratory services ordered in the client’s medical record as medically necessary and reference an appropriate diagnosis. Any test specimen sent to a laboratory for interpretation should not be billed on the family planning provider’s claim. The laboratory bills Texas Medicaid directly for the tests the laboratory performs. All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments (CLIA). Providers not complying with CLIA will not be reimbursed for laboratory services. Only the office or lab actually performing the laboratory test procedure and holding the appropriate CLIA certificate may bill for the procedure.

A provider that does not perform the laboratory procedure may be reimbursed one lab-handling fee per day, per client, unless multiple specimens are obtained and sent to different laboratories. Procedure code 99000 with modifier FP is paid for handling and/or conveyance of the specimen for transfer from the physician’s office to a laboratory.

Handling fees are not paid for Pap smears or cultures. When billing for Pap smear interpretations, the claim must indicate that the screening and interpretation were actually performed in the office by using the modifier SU, procedure performed in physician’s office (e.g., 88150- SU).

Providers must forward the client’s name, address, Medicaid number, and a family planning diagnosis with any specimen, including Pap smears, to the reference laboratory so the laboratory may bill the WHP for its family planning lab services.

When family planning test specimens, such as Pap smears, are collected, providers must direct the laboratory to indicate that the claim for the test is to be billed as a family planning service (i.e., procedure must be billed with a WHP qualifying diagnosis code). Refer to: “Diagnosis Codes” on page O-3 for a list of WHP qualifying diagnosis codes. Laboratory services may be submitted using the following procedure codes. Appropriate documentation must be kept in the client’s record.

Procedure Codes

80061 81000 81001 81002 81003 81015 81025 82947 82948 84702 84703 85013 85014 85018 85025 85027 86318 86580 86592 86689 86701 86703 86762 86803 8690086901 87070 87086 87088 87102 87110 87205 87210 87220 87340 87480 87490 87491 87510 87590 87591 87621 87660 87797 87800 87810 87850 88141 88142 88150 88164 88175 Q0111

Procedure code 87797 will be denied if submitted for the same date of service as procedure code 87800. Providers are reminded to code to the highest level of specificity with a diagnosis to support medical necessity when submitting procedure code 87797. Claims may be subject to retrospective review if they are submitted with diagnosis codes that do not support medical necessity. If more than one of procedure codes 87480, 87510, 87660, or 87800 is submitted by the same provider for the same client with the same date of service, all of the procedure codes will be denied. Procedure codes 87480, 87510, 87660, 87797, and 87800 are not payable in the inpatient hospital setting.

Code Group 2 (requires a diagnosis code from list below):

88141 – 88143, 88147, 88148, 88150, 88152 – 88155, 88164 – 88167, 88174, 88175

Diagnosis Code(s) Code Group 2:

• ICD-9: V70.0, V72.31, V72.32, V76.2

• ICD-10: Z00.00, Z00.01, Z01.411, Z01.419, Z12.4




Code Code Type Description: Pap test

88141  Cytopathology, cervical or vaginal, interpretation by physician

88142  Cytopathology, cervical or vaginal, manual screening under physician supervision

88143 Cytopathology, cervical or vaginal, manual screening and rescreening under physician supervision

88147 Cytopathology smears, cervical or vagina, screening by automated system under physician supervision

88148 Cytopathology smears, cervical or vagina, screening by automated system with manual rescreening under physician supervision

88150 Cytopathology, slides, cervical or vaginal, manual screening, under physician supervision

88152 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening, under physician supervision

88153 Cytopathology, slides, cervical or vaginal, manual screening and rescreening under physician supervision

88154 Cytopathology, slides, cervical or vaginal manual screening, computer assisted rescreening, under physician supervision

88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation

88164 Cytopathology, slides, cervical or vaginal, manual screening, under physician supervision

88165 Cytopathology, slides, cervical or vaginal, manual screening and rescreening, under physician supervision

88166 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening, under physician supervision

88167 Cytopathology, slides, cervical or vaginal, manual screening and computer assisted rescreening using cell selection, under physician supervision

88174 Cytopathology, cervical or vaginal collected in preservation fluid, automated thin layer preparation, screening by auto system, under phys super

88175 Cytopathology, cervical or vaginal collected in preservation fluid, screening by automated system, and manual rescreening, under physician super

G0123 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, screening by cytotechnologist under physician supervision

G0124 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, requiring physician interpretation

G0141 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, with manual rescreening, requiring physician interpretation

G0143 Screening Cytopathology, cervical or vaginal, auto thin layer preparation, with manual screening/ rescreening by cytotechnologist, under phys super

G0144 Screening Cytopathology, cervical or vaginal, automated thin layer preparation, with screening by automated system, under physician supervision

G0145 Screening Cytopathology, cervical or vaginal, automated thin layer prep, with screening by auto system w manual rescreening under phys super

G0147  Screening Cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

G0148 Screening Cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening

P3000 Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision

P3001 Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician

Q0091 Screening Papanicolaou smear, obtaining, preparing and conveyance of cervical or vaginal smear to laboratory




Edit procedure code Guidelines

88141+ (Cytopathology, cervical or vaginal {any reporting system}; requiring interpretation by physician {list separately in addition to code for technical service), 88142 (Cytopathology, cervical or vaginal {any reporting system}, collected in preservation fluid, automated thin layer preparation; manual screening under physician supervision) 88143 (Cytopathology, cervical or vaginal {any reporting system; with manual screening and rescreening under physician supervision), 88147 (Cytopathology, smears, cervical or vaginal; screening by automated system under physician supervision), 88148 (Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision), 88150 (Cytopathology, slides, cervical or vaginal; manual screening under physician supervision), 88152 (Cytopathology, slides, cervical or vaginal; with manual screening and computerassisted rescreening under physician supervision), 88153 (Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision), 88154 (Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision), 88155+ (Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation {e.g., maturation index, karyopyknotic index, estrogenic index} {List separately in addition to code(s) for other technical and interpretation services}), 88164 (Cytopathology, slides, cervical or vaginal  {the Bethesda System}; manual screening under physician supervision), 88165 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and rescreening under physician supervision), 88166 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer assisted rescreening under physician supervision), 88167 (Cytopathology, slides, cervical or vaginal {the Bethesda System}; with manual screening and computer-assisted rescreening using cell selection and review with physician supervision), 88174 (Cytopathology, cervical or vaginal
{any reporting system}, collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision) and 88175 (Cytopathology, cervical or vaginal {any reporting system}, collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision) bundles with 99201-99215, 99241-99245, 99304-99316, 99318, 99324-99337, 99341-99350, 99381-99397 and 99450-99456 (Outpatient services, nursing facility services, domiciliary/rest home/boarding home or custodial care services, home services, preventive medicine services and special evaluation and management services).

Denial code CO 197 & N347, N20

CO-197 -Precertification/authorization/notification absent.

Some of the  carriers request to obtaining prior authorization from them before the serivce/surgery.  This may be required for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific.  Please note that it is the responsibility of the Physician/Surgeon and not the patient to obtain the authorization# from the carrier.

When you get a denial from the carrier for this reason, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.


For some major procedureor all procedures or carrier specific we have to obtain the Pre Certification or Prior Authirization before the service performed. This is purely responsible of the Physician or Surgeon and not the  patient have.

If we received this denail from the carrier, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.




REMARK CODES & REASON:

N20 - Service not payable with other service rendered on the same date.

N347 - Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

M86 - Service denied because payment already made for same/similar procedure within set time frame

If we received   “Duplicate” denial with the above remark codes, we have to check the below check points.


Need to check if this same procedure/service was rendered/paid to another provider.
Need to submit with appropriate modifier (76/77) after confirmation with Coding Team. Even for EKG 93010 we get Duplicate denial, since we are billing repeatedly this code with combination of 93010-without modifier, 93010 -59,9310-59&76, 93010-76 (Based on EKG document performed timing) same DOS - Cardiology specialist.


DUPLICATE  DENIAL CODE WITH DESCRIPTION:

18 - Duplicate claim/service.

Reason for Denial 

Insurance received the same claim more than one time.
Actions for Denial
Check the system whether the claims has been already paid/denied if  yes ignore the denial or follow the below one.
Check the denial history and resubmission history if we submitted the claim more than once without any changes (same dos, procedure, diagnosis code and doctor.)  please resubmit the claims with necessary changes as corrected claim.
If no payment or denial in the claim, we have to get the original claim status through calling or Online
To avoid this denial in the future

If any correction like append modifier/ICD changes/corrected Referring physician/obtained Auth/Referral/Changes in Units/Changes in Billed Amount we have update the claim as “CORRECTED CLAIM” in software. (CMS 1500-CLAIM NOTE Tab)

REMARK CODE N56, CO97, CO 181 AND N390 , 125

Q: We received a RUC for claim adjustment reason code (CARC) CO 181. What steps can we take to avoid this RUC code?

Procedure code was invalid on the date of service.

A: You received this RUC because the claim contained outdated procedure code(s).

• Use the most current year’s CPT® codes books.

• CMS updates procedure codes on a quarterly basis (January, April, July and October). Although a code may currently be valid, it may not be valid for the date(s) of service on your claim. Check the CMS Healthcare Common Procedure Coding System (HCPCS) Quarterly update website external link.

• Verify procedure codes are valid, allowed and payable under the Medicare program for the date(s) of service, via the Medicare physician fee schedule lookup tool, available on the First Coast provider website

• Consider ABILITY | PC-ACE™ software, offered by First Coast, and updated with the most current CPT® codes, to ensure claims are submitted with valid procedure codes. Click here for information on ABILITY | PC-ACE™ software.

• Submit separate claims for services in different years of service. A procedure code valid one year may not be valid in another, and will cause the entire claim to reject or deny.

Contractors return as unprocessable services for HCPCS with payment indicator D5 (Deleted/discontinued code; no payment made.) and use the following messages:

• Claim Adjustment Reason Code 181 - Procedure was invalid on the date of service.

•x  RA Remark  N56 - Procedure code billed is not correct/valid for the services billed or the date of service billed.

Contractors shall deny services for HCPCS with payment indicators L1 (Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made.), NI (Packaged service/item; no separate payment made.) or S1 (Service not surgical in nature; and not a radiology service payable under the OPPS, drug/biological, or brachytherapy source.

Contractors return as unprocessable services for HCPCS with payment indicator D5 (Deleted/discontinued code; no payment made.) and use the following messages:

• MSN 16.32 - Medicare does not pay separately for this service.

• Claim Adjustment Reason Code 97 - The benefit for this service is included in the payment allowance for another service/procedure that has already been adjudicated.

• RA Remark - N390 - This service cannot be billed separately.

Contractors shall return as unprocessable services for HCPCS with payment indicators B5 (Alternative code may be available; no payment made.) and use the following messages:

• Claim Adjustment Reason Code - 125 - Submission/billing error.

• RA Remark - M51 - Missing/incomplete/invalid procedure code(s).

• RA Remark – M16 - Alert: Please see our web site, mailings or bulletins for more details concerning this policy/procedure/decision.

Remark code N428, 5 and N425, CA96

Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 

Contractors shall deny services for HCPCS with payment indicators C5 (Inpatient surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid under another fee schedule), U5 (Surgical unlisted service excluded from ASC payment. No payment made.), or X5 (Unsafe surgical procedure in ASC. No payment made. Use the following messages:

• MSN 16.2 - This service cannot be paid when provided in this location/facility.

• RA Remark N428 - Service/procedure not covered when performed in this place of service.

• Claim Adjustment Reason Code 5 - The procedure code/bill type is inconsistent with place of service.




Contractors shall deny services for CPT codes with payment indicators E5 (Surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.), or Y5 (Non-surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made.) and use the following messages:

• MSN 16.10 – Medicare does not pay for this item or service.

• Claim Adjustment Reason Code 96 – Non-covered charges.

• RA Remark Code - N425 - Statutorily excluded services.


• RA Remark Code M16 - Alert: Please see our Web site, mailings, or bulletins for more details concerning this policy/procedure/decision.

NOTE: Contractors shall assign beneficiary liability for facility charges HCPCS codes billed with ASC payment indicators C5, E5, U5 and X5. 

ASC denial - N200, M97 AND M15

Contractors shall deny globally billed ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages: 

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• N200 – The professional component must be billed separately

• Claim Adjustment Reason Code 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing. Note Refer to the 835 healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.






Contractors shall deny separately billed implantable devices using the following messages: 
• MSN 16.32 – Medicare does not pay separately for this service.

• RA Remark Code M97 - Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility.


• RA Remark Code M15 - Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed;

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.

• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision.(contractor discretion)

If there is a related, approved surgical procedure for the billing ASC for the same date of service, also include the following message:

• MSN 16.8 - Payment is included in another service received on the same day.

ASC denial code N95, MA 109 AND M97

Contractors shall deny services not included on the ASC facility payment files (ASCFS and ASC DRUG files) when billed by ASCs (specialty 49) using the following messages:

• Claim Adjustment Reason Code 8 - The procedure code is inconsistent with the provider type/specialty.

• RA Remark Code N95 - This provider type/provider specialty may not bill this service.

• MSN 26.4 - This service is not covered when performed by this provider.





If there is no approved ASC surgical procedure on the same date for the billing ASC in history, contractors shall return pass-through device claims/line items, brachytherapy claims/line items, drug code (including C9399) claims/line items, and any other ancillary service claims/line items such as radiology procedure claim/line items on the ASCFS list or ASCDRUG list as unprocessable using the following messages:

• Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate.

• RA Remark Code MA 109 - Claim processed in accordance with ambulatory surgical guidelines.


• RA Remark Code M16 - Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).







Contractors shall deny the technical component for all ancillary services on the ASCFS list billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages:

• MSN 16.2 – This service cannot be paid when provided in this location/facility.

• Claim Adjustment Reason Code 171 - Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

• Remittance Advice Remark Code M97 – Not paid to practitioner when provided in this place of service. Payment included in the reimbursement issued the facility.

• Remittance Advice Remark Code M16 – Please see our Web site, mailings or bulletins for more details concerning this policy/procedure/decision (at contractor discretion).

Reason code 30940, provider not permitted to adjust

A PROVIDER IS NOT PERMITTED TO ADJUST A PARTIALLY OR FULLY MEDICALLY DENIED CLAIM.

Q: We are receiving a return to provider (RTP) reason code 30940, so what steps can we take to avoid this reason code?

A: You will receive this reason code when you attempt to adjust a partially or fully medically denied claim. You are not permitted to adjust claims that are medically approved or denied.

Prior to correcting any claim, it is recommended that you review each line item service billed to determine if it has been medically denied or approved.

When the claim is within the timely filing limit, and there is medically denied line item(s) present:

• Cancel the original claim using type of bill (TOB) XX8
• If for a simple change, billing issue or to add/delete line items
• You are not permitted to cancel claims using direct data entry (DDE). You must cancel the claim though other electronic means or a hard copy (CMS-1450 form [UB-04]).
• Resubmit a corrected claim once the canceled claim has finalized (should take approximately two days)
• Add comments/remarks to the claim, must include all changes made
When the claim is beyond the timely filing limit, and a medically denied line item(s) present:
• Do not cancel and resubmit the claim
• Request a claim reopening using TOB XXQ
• If for a simple change, or billing issue
• You are not permitted to submit TOB XXQ using hard copy claims (CMS-1450 form [UB-04]). You must request the claim reopening via electronic media claims (EMC) or DDE.

If original claim does not include medically denied/reviewed lines, DDE users can F9 claim to reprocess.

If you do not agree with the decision for the medically denied line(s) and are within the time limit, you may submit a first level of appeal-redetermination.

Preventing duplicate claim denials - with example

Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and/or modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. (An example is listed below.) In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.


Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate. Please review the Current Procedural Terminology (CPT®) codebook for a complete list of modifiers.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances.

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59. Refer to MLN Matters® article MM8863 external pdf file for details.
• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.
• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT® code 82948).
Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

• Modifiers RT (right side) and LT (left side): Append applicable modifier to the procedure code, even if the diagnosis indicates the exact site of the procedure.

• Example: Provider submits Medicare claim for diagnosis code M1711 (unilateral primary osteoarthritis, right knee) and/or diagnosis code M1712 (unilateral primary osteoarthritis, left knee). Modifier RT should be added to the procedure code billed with diagnosis code M1711. Modifier LT should be added to the procedure code billed with diagnosis code M1712.

How insurance handling incomplete or invalid claims

Handling Incomplete or Invalid Claims

Claims processing specifications describe whether a data element is required, not required, or conditional (a data element which is required when certain conditions exist). The status of these data elements will affect whether or not an incomplete or invalid claim (hardcopy or electronic) will be "returned as unprocessable" or “returned to provider” (RTP) by the carrier or FI, respectively. The carrier or FI shall not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.

If a data element is required and it is not accurately entered in the appropriate field, the carrier or FI returns the claim to the provider of service.

• If a data element is required, or is conditional (a data element that is required when certain conditions exist) and the conditions of use apply) and is missing or not accurately entered in its appropriate field, return as unprocessable or RTP the claim to either the supplier or provider of service.

NOTE: Effective for claims with dates of service (DOS) on or after the implementation date of the ordering and referring phase 2 edits, Part B clinical lab and imaging technical or global component claims, Durable Medical Equipment, Prosthetics, claims and Home Health Agency (HHA) claims shall be denied, in accordance with CMS-6010-F final rule published on April 24, 2012, if the ordering or referring provider’s information is invalid or if the provider is not of a specialty that is eligible to order and refer.

• If a claim must be returned as unprocessable or RTP for incomplete or invalid information, the carrier or FI must, at minimum, notify the provider of service of the following information:

o Beneficiary’s Name;

o Claim Number; HIC Number or HICN or Health Insurance Claim Number. This has never been HI Claim Number.

o Dates of Service (MMDDCCYY) (Eight-digit date format effective as of October 1, 1998);

o Patient Account or Control Number (only if submitted);

o Medical Record Number (FIs only, if submitted); and

o Explanation of Errors (e.g., Remittance Advice Reason and Remark Codes)

NOTE: Some of the information listed above may in fact be the information missing from the claim. If this occurs, the carrier or FI includes what is available.

Depending upon the means of return of a claim, the supplier or provider of service has various options for correcting claims returned as unprocessable or RTP for incomplete or invalid information. They may submit corrections either in writing, on-line, or via telephone when the claim was suspended for development, or submit as a “corrected” claim or as an entirely new claim if data from the original claim was not retained in the system, as with a front-end return, or if a remittance advice was used to return the claim. The chosen mode of submission, however, must be currently supported and appropriate with the action taken on the claim.

NOTE: The supplier or provider of service must not be denied any services (e.g., modes of submission or customer service), other than a review, to which they would ordinarily have access.

• If a claim or a portion of a claim is “returned as unprocessable” or RTP for incomplete or invalid information, the carrier or FI does not generate an MSN to the beneficiary.

• The notice to the provider or supplier will not contain the usual reconsideration notice, but will show each applicable error code or equivalent message.

• If the carrier or FI uses an electronic or paper remittance advice notice to return an unprocessable claim, or a portion of unprocessable claim:

1. The remittance advice must demonstrate all applicable error codes. However, there must be a minimum of two codes on the remittance notice (including code Remittance Advice Remark Code : MA130).

2. The returned claim or portion must be stored and annotated, as such, in history, if applicable. If contractors choose to suspend and develop claims, a mechanism must be in place where the carrier or FI can re-activate the claim or portion for final adjudication.



A. Special Considerations

• If a “suspense” system is used for incomplete or invalid claims, the carrier or FI will not deny the claim with appeal rights if corrections are not received within the suspense period, or if corrections are inaccurate. The carrier must return the unprocessable claim through the remittance process, without offering appeal rights, to the provider of service or supplier. The FI uses the RTP process.

For assigned and unassigned claims submitted by beneficiaries (Form CMS-1490S), that are incomplete or contain invalid information, contractors shall manually return the claims to the beneficiaries. If the beneficiary furnishes all other information but fails to supply the provider or supplier’s NPI, and the contractor can determine the NPI using the NPI registry, the contractor shall continue to process and adjudicate the claim. If the contractor determines that the provider or supplier was not a Medicare enrolled provider with a valid NPI, the contractor shall follow previously established procedures in order to process and adjudicate the claim.

Contractors shall send a letter to the beneficiary with information explaining which information is missing, incorrect or invalid; information explaining the mandatory claims filing requirements; instructions for resubmitting the claim if the provider or supplier refuses to file the claim, or enroll in Medicare, and shall include language encouraging the beneficiary to seek non-emergency care from a provider or supplier that is enrolled in the Medicare program. Contractors shall also notify the provider or supplier about his/her obligation to submit claims on behalf of Medicare beneficiaries and that providers and suppliers are required to enroll in the Medicare program to receive reimbursement.

Contractors shall consider a complete claim to have all items on the Form CMS-1490S completed along with an itemized bill with the following information: date of service, place of service, description of each surgical or medical service or supply furnished; charge for each service; treating doctor’s or supplier’s name and address; diagnosis code; procedure code and the provider or supplier’s NPI. Required information on a claim must be valid for the claim to be considered as complete.

If a beneficiary submits a claim on the Form CMS-1500, return the Form CMS-1500 claim to the beneficiary, and include a copy of the Form CMS-1490S, along with a letter instructing the beneficiary to complete and return the Form CMS-1490S for processing within the time period prescribed in §70.5 above. Include in the letter a description of missing, invalid or incomplete items required for the Form CMS-1490S that were not included with the submitted Form CMS-1500 or were invalid.



NOTE: Telephone inquiries are encouraged.

• The carrier or FI shall not return an unprocessable claim if the appropriate information for both “required” and “conditional” data element requirements other than an NPI when the NPI is effective is missing or inaccurate but can be supplied through internal files. Contractors shall not search their internal files to correct missing or inaccurate “required” and “conditional” data elements required under Sections 80.3.2.1.1 through 80.3.2.1.3 and required for HIPAA compliance for claims governed by HIPAA.

• For either a paper or electronic claim, if all “required” and “conditional” claim level information that applies is complete and entered accurately, but there are both “clean” and “dirty” service line items, then split the claim and process the “clean” service line item(s) to payment and return as unprocessable the “dirty” service line item(s) to the provider of service or supplier. NOTE: This requirement applies to carriers only.

No workload count will be granted for the “dirty” service line portion of the claim returned as unprocessable. The “clean” service line portion of the claim may be counted as workload only if it is processed through the remittance process. Contractors must abide by the specifications written in the above instruction; return the “dirty” service line portion without offering appeal rights.

• Workload will be counted for claims returned as unprocessable through the remittance process. Under no circumstances should claims returned as unprocessable by means other than the remittance process (e.g., claims returned in the front-end) be reported in the carrier or FI workload reports submitted to CMS. The carrier or FI is also prohibited from moving or changing the action on an edit that will result in an unprocessable claim being returned through the remittance process. If the current action on an edit is to suspend and develop, reject in the front or back-end, or return in the mailroom, the carrier or FI must continue to do so. Workload is only being granted to accommodate those who have edits which currently result in a denial. As a result, workload reports should not deviate significantly from those reports prior to this instruction.


NOTE: Rejected claims are not counted as an appeal on resubmissions.

B. Special Reporting of Unprocessable Claims Rejected through the Remittance Process (Carriers Only):

Carriers must report “claims returned as unprocessable on a remittance advice” on line 15 (Total Claims Processed) and on line 14 (subcategory Non-CWF Claims Denied) of page one of your Form CMS-1565. Although these claims are technically not denials, line 14 is the only suitable place to report them given the other alternatives. In addition, these claims should be reported as processed “not paid other” claims on the appropriate pages (pages 2-9) of CROWD Form T for the reporting month in which the claims were returned as unprocessable through the remittance process. Also, carriers report such claims on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) system. They report the “number of such claims returned during the month as unprocessable through the remittance process” under Column 1 of Form Y on a line using code “0003” as the identifier.

If a supplier, physician, or other practitioner chooses to provide missing or invalid information for a suspended claim by means of a telephone call or in writing (instead of submitting a new or corrected claim), carriers do not report this activity as a claim processed on Form CMS-1565/1566. Instead, they subtract one claim count from line 3 of Form Y for the month in which this activity occurred.

EXAMPLE: Assume in the month of October 2001 the carrier returned to providers 100 claims as unprocessable on remittance advices. The carrier should have included these 100 claims in lines 14 and 15 of page 1 of your October 2001 Form CMS-1565. During this same month, assume the carrier received new or corrected claims for 80 of the 100 claims returned during the month. These 80 claims should have been counted as claims received in line 4 of your October 2001 Form CMS-1565 page one (and subsequently as processed claims for the reporting month when final determination was made).

Also, during October 2001, in lieu of a corrected claim from providers, assume the carrier received missing information by means of a telephone call or in writing for 5 out of the 100 claims returned during October 2001. This activity should not have been reported as new claims received (or subsequently as claims processed when adjustments are made) on Form CMS-1565. On line 3 of Form Y for October 2001, the carrier should have reported the number 95 (From claims returned as unprocessable through the remittance process minus 5 claims for which the carrier received missing or invalid information by means of a telephone call or in writing.

For the remaining 15 claims returned during October 2001 with no response from providers in that same month, the carrier should have reported on the Form CMS-1565 or Form Y, as appropriate, any subsequent activity in the reporting month that it occurred. For any of these returned claims submitted as new or corrected claims, the carrier should have reported their number as receipts on line 4 of page one of Form CMS-1565. For any of these returned claims where the supplier or provider of service chose to supply missing or invalid information by means of a telephone call or in writing, the carrier should not have counted them again on Form CMS-1565, but subtracted them from the count of returned claims reported on line 3 of Form Y for the month this activity occurred.


C. Exceptions (Carrier Only)

The following lists some exceptions when a claim may not be “returned as unprocessable” for incomplete or invalid information.
Carriers shall not return a claim as unprocessable:

If a patient, individual, physician, supplier, or authorized person’s signature is missing, but the signature is on file, or if the applicable signature requirements have been met, do not return a claim as unprocessable where an authorization is attached to the claim or if the signature field has any of the following statements (unless an appropriate validity edit fails):

Acceptable Statements for Form CMS-1500:

• For items 12, 13, and 31, “Signature on File” statement and/or a computer generated signature;

• For items 12 and 13, Beneficiary’s Name “By” Representative’s Signature;

For item 12, “X” with a witnessed name and address. (Chapter 26 for instructions.)