Monday, July 19, 2010

CMS 1500 claim troubleshooting - reverification

CLAIM TROUBLESHOOTING

This section provides information about the most common billing errors encountered when
providers submit claims to the Medical Assistance Program. Preventing errors on the claim
is the most efficient way to ensure that your claims are paid in a timely manner.

Each rejected claim will be listed on your remittance advice along with an Explanation of Benefits (EOB) code that provides the precise reason a specific claim was denied. EOB codes are very specific to individual claims and provide you with detailed information about the claim. The information provided below is intended to supplement those descriptions and provide you with a summary description of reasons your claim may have been denied.

Claims commonly reject for the following reasons:


1. The appropriate provider and/or recipient identification is missing or inaccurate.

�� Verify that your NPI and 9-digit Medical Assistance provider numbers are entered in Blocks #33a/b. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. Do not use your PIN or tax identification number.

�� Verify that a valid NPI and 9-digit Medical Assistance provider number for the requesting, referring or attending provider are entered in the Blocks #17a/b and each provider is correctly identified. The ID Qualifier 1D must precede the 9- digit Medical Assistance provider number in block 17a.

Note: Completion of 17-17b is only required for Lab and Other Diagnostic Services.

�� Verify that the NPI and 9-digit rendering Medical Assistance provider number you entered in Block #24j. is in fact, a rendering provider. The ID Qualifier 1D must precede the 9-digit Medial Assistance provider number. If you enter a group NPI and provider number in the block for the rendering provider, the claim will deny because group provider numbers cannot be used as rendering provider numbers.

�� When billing for preauthorized procedures, verify that the 9-digit provider number entered on the claim form is the same 9-digit provider number that was authorized to provide the services.

�� Verify that the recipient’s 11-digit Medical Assistance identification number is entered in the Block #9a.

�� Verify that the recipient’s name is entered in Block #2, last name first.

�� When billing for preauthorized procedures, verify that the 11-digit recipient number entered on the claim form is the same 11-digit recipient number that was authorized to receive the services.

�� Verify that you did not use the mother’s 11-digit number if you are billing for services provided to a child. Age and procedure codes will ensure that such claims are automatically rejected.

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