Medicare Rejection as Annual Threapy cap limit and service was hospice election period

Q: We are receiving reject reason code 76474, so what steps can we take to avoid this reason code?
A: You are receiving this reason code when the patient has met the Medicare annual therapy cap limit for the calendar year.
• Confirm the beneficiary’s physical and occupational therapy cap information via the following:
• Interactive voice response (IVR) system
• Main menu select option 5 for Eligibility, then select option 3 for physical and occupational therapy information.
or
• Secure Provider Online tool (the SPOT) the Eligibility/Benefits Inquiry page, if the required beneficiary information is entered, the Benefits/Eligibility submenu will be visible and more beneficiary information/history will be accessible for example Deductibles/Caps with the following:
• Beneficiary’s Occupational Therapy information:
• Calendar Year -- the calendar year associated with the used dollar amount that has been applied to the capitation limit for occupational therapy services.
• Used Amount -- the used dollar amount that has been applied to the capitation limit for occupational therapy services for the calendar year indicated.
• Beneficiary’s Physical and Speech Therapy information:
• Calendar Year -- the calendar year associated with the used dollar amount that has been applied to the capitation limit for physical and speech therapy services.
• Used Amount -- the used dollar amount that has been applied to the capitation limit for physical and speech therapy services for the calendar year indicated.
• Refer to the Rehabilitation Services specialty page designed specifically for rehabilitation service providers.


Q: We are receiving reject reason code C7010. What steps can we take to avoid this reason code?

A: You are receiving this reason code when the beneficiary was/is enrolled in a hospice election period for the date of service(s).
• Confirm the beneficiary’s eligibility via direct data entry (DDE), interactive voice response (IVR) system, or Secure Provider Online Tool (the SPOT)
• If the information is invalid
Contact the hospice provider and ask them to submit their last claim for the beneficiary with occurrence code 42 and the date of disenrollment. Once the records are deleted or updated, refile the claim to Medicare
• If the information is valid and the services provided to the beneficiary are related to their terminal condition for hospice services
Refile the claim with the hospice provider listed on the beneficiary’s records
• If the information is valid and the services provided to the beneficiary are not related to their terminal condition for hospice services
Refile the claim with a condition code 07 (treatment of non-terminal condition for hospice patient)
SPOT Users:
• Select the Hospice/Home Health link from the Benefits/Eligibility submenu