Monday, July 19, 2010

CMS 1500 - rejected for unauthorized code

Claims commonly reject for the following reasons:

4. The medical services are not covered or authorized for the provider and/or recipient.

�� There are limits to the number of units that can be billed for certain services. Verify that you entered the correct number of units on the claim form.

�� A valid 2-digit place of service code is required. Please refer to the Place of Service List.

�� When billing for preauthorized procedures, verify that the units entered on the claim form are not more units then were authorized.

�� Some tests are frequently performed as groups or combinations and must be billed as such. Verify the procedure codes and modifiers that were entered on the claim form and determine if they should have been billed as a group.

�� Claims will be denied if the procedure cannot be performed on the recipient indicated because of gender, age, prior procedure or other medical criteria conflicts. Verify that you entered the correct 11-digit recipient identification number, procedure code and modifier on the claim form.

�� Verify that the billed services are covered for the recipient’s coverage type. Covered services vary by program type. For example, some recipients have coverage only for family planning services. If you bill the Program for procedures that are not for family planning, these are considered non-covered services and the Program will not pay you. Refer to regulations for each
program type to determine the covered services for that program.

�� Some procedures cannot be billed with certain place of service codes. Verify that you entered the correct procedure and place of service codes in the appropriate block on the claim form.

5. The claim is a duplicate, has previously been paid or should be paid by another party.

�� MMIS-II edits all claims to search for duplications and overlaps by providers. Verify that you have not previously submitted the claim.

�� If the Program has determined that a recipient has third party coverage that will pay for medical services, the claim will be denied. Submit the claim to the thirdparty payer first.

�� If a recipient is enrolled in an MCO, you must bill that organization for services rendered. Verify that the recipient’s 11-digit MA number is entered correctly on the claim form.

6. Required attachments are not included.
�� If you bill for an abortion, hysterectomy or sterilization, the appropriate form
must be attached and completed accurately. Verify that this has been done.
�� For some procedures there is no established fee and the claim must be
manually priced. These claims require that a report be attached. Verify that
you have completed such a report, attach it to the claim form and then
resubmit the claim.

Lastly, some errors occur simply because the data entry operators have incorrectly keyed
or were unable to read data on the claim. In order to avoid errors when a claim is scanned, please ensure that this information is either typed or printed clearly. When a claim is denied, always compare data from the remittance advice with the file copy of your claim. If the claim denied because of a keying or scanning error, resubmit the claim.

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