Rejection code 34538, 36428, 39929,76474, c7010 - solution

Q: We are receiving reject reason code 34538, so what steps can we take to avoid this reason code?
Click here http://medicare.fcso.com/parta_lookup/  for a description associated with the Medicare Part A reason code(s). Simply enter a valid reason code into the box and click the submit button.


A: You are receiving this reason code when the beneficiary or the spouse was/is working for the date of service(s) and the employer’s insurance is primary to Medicare.

• Upon patient registration and prior to submitting the claim, have the beneficiary complete the Medicare secondary payer (MSP) questionnaire external pdf file located in the Medicare Secondary Payer Internet-only manual (IOM), Publication 100-05, chapter 3, section 20.1.2.

• Confirm the beneficiary’s eligibility via direct data entry (DDE), the interactive voice response (IVR) system, or take advantage of the Secure Provider Online Tool (SPOT), where you can view claims status, eligibility and benefits, payment information, and comparative billing data in a secure online environment. Please follow this path to learn more about the SPOT as well as how to begin the registration process: http://medicare.fcso.com/Landing/256747.asp

If the information is invalid

The provider or the beneficiary must contact the Benefits Coordination & Recovery Center (BCRC) external link at 1-855-798-2627, to have the record updated. Once the record is updated, refile the claim to Medicare for primary payment consideration.


Q: What steps can we take to avoid reject reason code 36428?

Click here for a description associated with the Medicare Part A reason code(s). Simply enter a valid reason code into the box and click the submit button.

A: A claim for mammography screening services has been submitted, and either the Food & Drug Administration (FDA) certification records need to be updated or the mammography services are outside the scope of the FDA certificate on file.

There are two types of mammography services:
1. Computer aided detection/film
2. Digital

Refer to the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network (MLN) Preventive Services external pdf file resource for coding and billing information.
Ensure your FDA certification is for the "type" of mammography service you're providing and that the service is within the dates covered by the certificate.

• If your certification has expired, it must be updated prior to providing and billing mammography services
• Certification information may be updated with First Coast via mail or fax:
FDA Certification
P.O. Box 2078
Jacksonville, FL 32231-2078
Or,
Fax: 904-791-6336
Please allow at least seven business days for certification data to be updated.

• Submit claim adjustments for all claims that rejected with reason code 36428
• Click here for guidance on when to adjust a rejected claim
http://medicare.fcso.com/faqs/answers/0297002.asp


Q: My claim rejected, or was returned to provider, as a duplicate of another claim. Can I resubmit the claim? What steps can I take to avoid duplicate claims?

A: Claim system edits are in place to detect duplicate services. The edits search within paid, finalized, pending, and same claim details in history. This means that unless applicable modifiers and/or condition codes are included in your claim, the edits will detect duplicate and repeat services within the same claim, and/or based on a previously submitted claim.

The following reject reason codes are commonly seen with this edit
• 38005 -- This claim is a duplicate of a previously submitted inpatient claim
• 38031 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim
• 38035 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider
• 38038 – This claim is a possible duplicate of a previously submitted claim
• 38200 -- This is an exact duplicate of a previously submitted claim
The following return to provider (RTP) reason codes are commonly seen with this edit:
• 38032 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
• 38037 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
Your claim rejected as a duplicate, because one or more of the following items matches the original claim:

• Health Insurance Claim Number (HICN), provider number, type of bill (TOB)--all three positions of any TOB, statement coverage from and through dates, at least one diagnosis or line item date of service, revenue code, HCPCS code, and/or total charges (0001 revenue line).
To avoid this duplicate in the future, verify the status of your claim(s) prior to filing. There are several ways to do this:

1. If you use direct data entry (DDE) pdf file, access the beneficiary's HIC number to verify the history of claims submitted and the status/location of those claims. Note: you cannot see claims submitted by other facilities.

2. Check status of claims via the Secure Provider Online Tool (SPOT).
3. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816. There are three breakdowns available: claim status, return to provider and pending claims.
4. Review the remittance advice for the history of the beneficiary's claims.
In addition, if your claim includes repeat services or supplies, append modifiers and/or condition codes, as applicable. For a complete list of coding resources, refer to the Medicare Billing: 837I and Form CMS-1450 Fact Sheet external pdf file


If you submit claims via the electronic data interchange (EDI) gateway, you are provided with confirmation when the batch of claims is received. Please wait for this confirmation, instead of resubmitting the batch of claims. If you make one change to one claim in the batch but resubmit the entire batch, all the claims go to the fiscal intermediary shared system (FISS), resulting in duplicate claims. Do not resubmit the entire batch; resubmit corrected claims only.

Note: If a third party vendor, billing service, or clearinghouse submits claims on your behalf, contact them to ensure they are not resubmitting entire batches of claims as described above. In addition, occasional software glitches can cause the resubmittal of an entire batch. Be aware that these software or vendor issues reflect directly upon the provider and are problematic, at best, and considered possible abuse, at worst.

Listed below are some recommendations, when additional action is required to correct your claim(s):
• You have two options when the original processed claim needs to be updated or corrected.
1. Adjust the original processed claim (TOB xx7) and resubmit.
2. Cancel the original processed claim (TOB xx8) and submit a new claim, but you must wait for the cancelled claim to finalize before the new claim is submitted.
• If two claims were submitted at the same time and resulted in duplicates against each other, submit a new claim.
• If the rejected claim is an exact duplicate to a previously processed/finalized claim, no action is necessary.



Q: We are receiving reject reason code 39929, so what steps can we take to avoid this reason code?

A: You are receiving this reason code which indicates the claim has rejected due to all line items rejecting and/or rejected and denied. There could be several reasons your claim is receiving this reject reason code. There are several ways you can review the claim and see the line item reason code:
Direct data entry (DDE) pdf file users -- open the claim and go to page 2, press the F2 key to take you to the breakdown for line items on page MAP171D (in the top left corner of the page). Here you will look at the bottom for the line item reason code. Once you have this reason code, you can PF1 and key the number in the reason code field to pull the description.

• If the claim is in a rejected status, you may adjust the claim, fix the line item, and resubmit.
• If the claim is in a denied status, you may not adjust a denied line item. You must go through the appeals process. Click here for more information regarding appeals.
• Review the 201 report through DDE for history of the claims submitted.
• Review the remittance advice to obtain a history of the claims submitted.
There can be numerous reason codes that can fall under the code 39929. A few examples of a line item reason code is:
• W7049 -- service on the same day as inpatient procedure
• W7018 -- inpatient procedure


: 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
SPOT Eligibility submenu
• The beneficiary’s Hospice results will include the following information:
• Effective Date
• Termination Date
• Revocation Code:
0 = No revocation, open spell
1 = Revoked by beneficiary
2 = Revoked (occurrence code 42)
3 = Revoked (occurrence code 23)
• National Provider Identifier (NPI)
Search the NPI Registry external pdf file for the hospice provider’s contact information
• Hospice Occurrence Count (when applicable)



Q: We are receiving reject reason code T5052. What steps can we take to avoid this reason code?
A: You are receiving this reason code when the Centers for Medicare and Medicaid Services (CMS) records indicate the beneficiary is not on file. Verify the beneficiary’s Medicare health identification number and resubmit the claim if the patient is eligible for Medicare Part A coverage.
There are several ways to obtain beneficiary eligibility:
• Users can access eligibility information via direct data entry (DDE) pdf file.
• Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
• 270/271 eligibility transactions external link -- you can obtain eligibility information in a batch format for a number of beneficiaries.
• Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
Always remember to check with the beneficiary and/or representative for eligibility prior to submitting claims to Medicare.
There are also a few things you can do when a beneficiary comes to your facility:
• Always obtain a copy of the red, white, and blue Medicare card prior to providing services.
• Ensure the eligibility dates on the card indicate their coverage is currently valid and not expired or a future date.
• Make sure the name on the claim matches the name as it appears on the Medicare red, white, and blue card. Do not use nicknames.
• If everything matches on the Medicare card, the beneficiary should verify eligibility with the Social Security Administration (SSA)


Q: We are receiving claims rejected for reason code U5200, indicating no record of Part A entitlement for the beneficiary. What steps can we take to avoid this reject?
A: Check beneficiary eligibility prior to submitting claims to Medicare. Click here for ways to verify beneficiary eligibility.

Q: We are receiving reject reason code U5233. What steps can we take to avoid this reason code?
A: You are receiving this reason code which indicates the admission date falls within a risk Group Health Organization (GHO) paid period (aka Medicare Advantage (MA) plan). The beneficiary was/is enrolled in a Medicare replacement plan for the date of service(s) billed and the claim should be filed to that plan for payment
Many times a claim will overlap a GHO period because it was open at the time of billing, but was subsequently closed by the time the provider researches the reason for rejection. The best way to avoid this reason code is to verify the beneficiary has traditional Medicare right before submitting the claim.
There are several ways to obtain beneficiary eligibility to determine if in a GHO:
1. Users can access eligibility information via direct data entry (DDE) pdf file.
2. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816.
• Note: Customer service representatives cannot assist you with eligibility information and are required, by the Centers for Medicare & Medicaid Services (CMS), to refer you to the IVR.
3. 270/271 eligibility transactions external link-- you can obtain eligibility information in a batch format for a number of beneficiaries.
4. Confirm the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
5. Upon admission for Medicare covered services, review all insurance card(s) the beneficiary may hold and verify the information on the card with the patient or their legal representative and determine if all the information is still valid.
Additionally, Centers for Medicare & Medicaid Services (CMS) requires providers to submit no pay claims to the Medicare administrator contractors (MACs) to report the patient’s MA inpatient days, and bill certain inpatient claims for reimbursement through the Part A cost report. The MACs reimburse for disproportionate share hospital (DSH), indirect medical education (IME), direct graduate medical education (DGME), and nursing allied health (N&AH). This type of duplicate billing is often referred to as “shadow billing”, since claims are submitted to both the MA plan for payment and MAC as “no pay” or “information only” billing.
IPPS hospitals with disproportionate share of low-income patients
If a hospital meets the disproportionate share hospital (DSH) definition, an additional operating cost payment will be made.
Inpatient prospective payment system (IPPS) hospitals and inpatient rehabilitation facility (IRF) hospitals/units are required to submit informational only bills for purposes of capturing the MA patients inpatient days for inclusion in the Supplemental Security Income (SSI) ratio. This ratio is used in the DSH and low income patient (LIP) for the IRF’s PPS calculations. This also applies to long-term care hospitals (LTCHs) even though they do not directly receive DSH, as an estimate of what the facility would have received under DSH if they were an acute care facility becomes part of the LTCH outlier calculation.
Claim submission guidelines are as follows:
• Type of bill = 11X
• Condition code 04
• Covered days and charges
• Revenue code 0024 containing CMG (case-mix groups) A9999 and include the discharge date in the service date field (only required by IRFs)
Approved teaching IPPS hospitals indirect medical education (IME)
Approved teaching hospitals submit informational only bills for IME payment. The purpose is to capture the MA patients inpatient days for inclusion in the SSI ratio and the provider statistics & reimbursement report (PS&R) type 118.
Claim submission guidelines are as follows:
• Type of bill = 11X
• Condition code 04 and 69
• Covered days and charges
Hospitals and units excluded from IPPS for DGME and N&AH education
Non-IPPS hospitals and units submit their MA claims to their respective MACs to be processed as no-pay bills, so the inpatient days can be reported on the patient’s record and PS&R type 118 for DGME payment purposes through the cost report. This applies to the rehabilitation, psychiatric, long-term care, children’s and cancer hospitals, plus rehabilitation and psychiatric units.
Claim submission guidelines are as follows:
• Type of bill = 11X
• Non-covered days and charges
• Condition code 04 and 69
Skilled nursing facilities (SNFs) and swing bed units
SNF providers must submit bills for beneficiaries enrolled in MA plans and receiving skilled care in order to take benefit days from the beneficiary and/or update the beneficiary’s spell of illness in the Medicare’s common working file (CWF) system.
Claim submission guidelines are as follows:
• Type of bill = 21X or 18X
• Covered days and charges
• Condition Code 04


Q. If a claim is rejected for Medicare as a secondary payer (MSP) and the common working file (CWF) is updated, what action should be taken on the claim?
A. Follow the guidelines below if your claim falls within the status outlined:
• If your claim has rejected ("R" status), you should be able to adjust the claim and resubmit through your electronic software.
• If the claim has been returned to provider ("T" status), you should correct the errors and resubmit through your electronic software.
Remember you can only void/cancel a paid claim.