Friday, September 8, 2017

Getting Authorization for inpatient hospital visit

INPATIENT HOSPITAL AUTHORIZATION REQUIREMENTS

The information in this section applies to instate and borderland hospitals. Information regarding out-ofstate hospital authorization requirements can be found in the Out-of-State/Beyond Borderland Providers subsection of this chapter.

All inpatient admissions must be medically necessary and appropriate, and all services must relate to a specific diagnosed condition. In the event that an inpatient stay is deemed medically inappropriate or unnecessary, either through a pre-payment predictive modeling review or a post-payment audit, providers are allowed to submit an outpatient claim for all outpatient services and any inpatient ancillary services performed during the inpatient stay. Elective admissions, readmissions, and transfers for surgical and medical inpatient hospital services must be authorized through the Admissions and Certification Review Contractor (ACRC). The physician/dentist should refer to the Prior Authorization Certification Evaluation Review (PACER) subsection of this chapter for specific requirements.

Medically inappropriate or unnecessary inpatient admissions may be resubmitted as outpatient claims for all outpatient services and any inpatient ancillary services performed during the inpatient stay. When an inpatient claim is deemed medically inappropriate or unnecessary through a pre-payment predictive modeling review or a post-payment audit, hospitals are allowed to submit a hospital outpatient Type of Bill (TOB) 013X for all outpatient services and any inpatient ancillary services performed during the inpatient stay. Examples of services related to medically inappropriate or unnecessary inpatient admission include:

** all elective admissions, readmissions, and transfers that are not authorized through the PACER system;

** admissions or readmissions which have been inappropriately identified as emergent/urgent;

** selected ambulatory surgeries inappropriately performed on an inpatient basis; and

** any other inpatient admission determined to have not been medically necessary. Medicaid does not cover inpatient hospital admissions for the sole purpose of:

** Cosmetic surgery (unless prior authorized)

** Custodial or protective care of abused children

** Diagnostic procedures that can be performed on an outpatient basis

** Laboratory work, electrocardiograms (ECGs), electroencephalograms (EEGs), and diagnostic x-rays

** Observation

** Occupational Therapy (OT)

** Patient education

** Physical Therapy (PT)

** Routine dental care

** Routine physical examinations not related to a specific illness, symptom, complaint, or injury

** Speech pathology

** Weight reduction or weight control (unless prior authorized)

If Medicaid does not cover the services of the physician/dentist or hospital, the physician/dentist or hospital must not bill the beneficiary, a member of the beneficiary's family, or other beneficiary representative.


PRIOR AUTHORIZATION CERTIFICATION EVALUATION REVIEW (PACER)

Elective admissions, all readmissions within 15 days of discharge, continued stays (when appropriate), and all transfers for surgical or medical inpatient hospital services to and from any hospital enrolled in the Medicaid program require authorization through the ACRC. This includes transfers between a medical/surgical unit and an enrolled distinct part rehabilitation unit of the same hospital. All cases are screened using the Medicaid approved Severity of Illness/Intensity of Services (SI/IS) criteria sets and the clinical judgment of the review coordinator. An ACRC physician/dentist makes all adverse decisions. The ACRC performs medical/surgical and rehabilitation admission, readmission, and transfer reviews through the PACER system and assigns PACER numbers.

The attending/admitting physician/dentist or representative is responsible for obtaining the PACER number before admitting, readmitting, or transferring the beneficiary, with exceptions as noted below. (Refer to the Directory Appendix for PACER authorization contact information.) The physician/dentist is responsible for providing the PACER number to the admitting hospital. The PACER number is issued on the day that the admission is approved by the ACRC. This number is valid for the entire medical or surgical admission unless otherwise noted in this section. PACER authorization must be requested prior to the admission of the beneficiary. Physicians/dentists are asked to provide the procedure code(s) when a surgical admission/readmission is requested.

Authorization through the ACRC for the hospital admission does not remove the need for prior authorization (PA) required by Medicaid for specific services. The PA for the service must be obtained before the ACRC authorization is requested.

Approval of an admission only confirms the need for services to be provided on an inpatient hospital basis. Payment for the admission is subject to eligibility requirements, readmission, and third party liability (TPL) reimbursement policy, along with any pre- and post-payment determinations of medical  necessity.

If an admission, readmission, transfer, or continued stay is not approved, MDHHS does not reimburse for services rendered.


Reconsiderations The attending physician/dentist or the hospital may request reconsideration of the adverse determination of the ACRC regarding the need for admission, readmission, transfer, or continued stay. This reconsideration right applies regardless of the current hospitalization status of the beneficiary. Reconsiderations must be requested within three business days of the adverse determination. (Refer to the Directory Appendix for ACRC contact information.) If requested by the ACRC, the provider must provide written documentation. The provider is notified of the reconsideration decision within one business day of receipt of the request or the date of receipt of written documentation. If the initial adverse determination is overturned, the adverse determination is considered null and void. If the initial adverse determination is upheld or is modified in such a manner that some portion of the hospital care is not authorized, the hospital is liable for the cost of care provided from the date of the initial determination, unless this determination is overturned in the Medicaid appeals
process.

Technical Denials If the provider fails to request a PACER number on a timely basis, the provider should make this request as soon as the omission is noted. When the provider contacts the ACRC by telephone with an untimely request, the review coordinator sends the provider a form to complete, explaining the circumstances of the untimely request. If upon review of this written documentation the untimeliness is waived, the case is reviewed for medical necessity and the appropriateness of the admission, readmission, or transfer. If approved, the ACRC gives the provider a PACER number. If the untimeliness issue is not approved, the attending physician/dentist and the hospital are notified in writing within 24 hours of the decision. The physician/dentist or hospital may request further review of the ACRC decision by Medicaid relative to timeliness.


If the ACRC does not authorize the admission or the continued stay for an admission and the beneficiary remains in the hospital for one or more days after Medicaid payment is not authorized, the hospital is at risk of Medicaid nonpayment for those days. The provider may request post-discharge review by the ACRC, regardless of whether reconsideration was requested on the case, in writing within 30 calendar days of the discharge from the hospital. A copy of the medical record must accompany the post-discharge review request.

Post-discharge review is conducted for only those days that were not authorized during the telephone review. The ACRC informs the provider, in writing, of the ACRC decision within 14 calendar days of the receipt of the request and documentation. If some or all of the previously nonauthorized days are approved, a new PACER number is issued and included in the notification of the decision. If the initial adverse determination is upheld, the notification includes the previously issued PACER number. If the provider is dissatisfied with the decision of the ACRC, the decision may be appealed.

The hospital may bill Medicaid only for the days authorized by the ACRC. If the ACRC has made an adverse determination and issued a final PACER number, the hospital  may submit a claim with this PACER number for only the authorized days while the
case is in the reconsideration, post-discharge review, or formal appeals process. Submission of such a claim does not imply acceptance of the ACRC determination.


A. ADMISSIONS/READMISSIONS/TRANSFERS THAT REQUIRE A PACER NUMBER

The following require a PACER number:

** All elective admissions.

** All readmissions within 15 days of discharge (including newborns). [NOTE: If a beneficiary is readmitted to the same hospital within 15 days for a related (required as a consequence of the original admission) condition, Medicaid considers the admission and the related readmission as one episode for payment purposes. The related admissions must be combined on a single claim. No PACER number is issued for continuation of care.]

** All transfers for medical/surgical services to and from any hospital enrolled in the Medicaid program (including newborns).

** Transfers between a medical/surgical unit and an enrolled distinct part rehabilitation unit of the same hospital.

** Authorization of continued stays in freestanding and distinct part rehabilitation units.



B. ADMISSIONS/READMISSIONS/TRANSFERS THAT DO NOT REQUIRE A PACER NUMBER

The following do not require a PACER number:

** Emergent/urgent inpatient hospital admissions. (All transfers and 15-day readmissions to the same or a different hospital do require PACER through the ACRC.)

** All admissions and transfers to distinct-part psychiatric units or freestanding psychiatric hospitals and all continued stays in a psychiatric unit/hospital. (Authorization must be obtained through the local Prepaid Inpatient Health Plan (PIHP)/Community Mental Health Services Program (CMHSP).)

** Obstetrical patients admitted for any delivery.

** Newborns admitted following delivery.

** Admissions of beneficiaries who are eligible for CSHCS only.
** Medicaid beneficiaries enrolled in a Medicaid Health Plan (MHP). (Authorization must be obtained through the MHP.)

** When a beneficiary is admitted to a hospital that is not enrolled with the Michigan Medicaid Program.

** When a beneficiary becomes Medicaid eligible after the admission, readmission, transfer, or certification review period. (When Medicaid eligibility is determined retroactively, "Retroactive Eligibility" must be entered in the Remarks section of the inpatient hospital claim.)

** Medicare Part A beneficiaries.

** Commercial insurance coverage for admissions, readmissions, transfers, or continued stays.



PACER READMISSIONS

To be separately reimbursable, all readmissions (whether to the same or a different hospital) for hospital services must be prior authorized through the ACRC. The request for a PACER number for an elective readmission, whether to the same or a different hospital, must be made prior to readmission. The request for a PACER number for an emergent/urgent readmission to the same hospital must be made by the next business day following the readmission. The request for a PACER number for an emergent/urgent readmission to a different hospital must be made prior to the beneficiary's discharge from a transferring hospital. Medicaid defines readmission, for purposes of review, as any admission/hospitalization of a beneficiary within 15 days of a previous discharge, whether the readmission is to the same or a different hospital.

If the hospital intends to combine an admission and a readmission into a single episode for DRG payment purposes, the ACRC should not be contacted for a separate PACER number for the readmission.

Before contacting the ACRC, the provider should assemble as much information as possible regarding the medical condition of the beneficiary upon the first discharge and at the time of the readmission. When contacted for a PACER number, the ACRC either:

** Agrees that the original admission and the readmission are unrelated, as well as medically necessary, and issues a PACER number so that the stays may be billed and paid separately by the same hospital;

** Authorizes a readmission to a different hospital as medically necessary and issues a PACER number;

** Asks the caller to obtain additional information and call back no later than the next business day; or

** Questions the relatedness of two stays at the same hospital or the medical necessity for the readmission and refers the call to a physician/dentist advisor who may issue or deny a PACER number.

If a PACER number is not provided for a readmission due to relatedness (required as a consequence of the original admission), the hospital must combine the two stays into a single episode for DRG payment purposes (using the Leave of Absence revenue code 0180 for the time between discharge and readmission), or request reconsideration of the ACRC physician/dentist advisor's decision within three business days. If the initial admission has already been billed, the hospital must submit a claim
replacement to combine the two stays.

If it is determined a readmission is medically unnecessary, the hospital may only bill for the first admission.


PACER TRANSFERS

If a beneficiary needs to be transferred, authorization for the transfer must be obtained through the ACRC. Authorization for a transfer is granted only if the transfer is medically necessary and the care or treatment is not available at the transferring hospital. Transfers for convenience are not considered.

Transfers include the following situations:

** Transfer from one inpatient hospital to another.

** Transfer from one unit of an inpatient hospital to another unit of the same hospital (i.e., distinctpart rehabilitation unit).

The following describes the appropriate requestor and timeframes for transfer authorization:

** Elective transfers – the transferring physician/dentist or designee must obtain authorization prior to transfer.

** Emergent/urgent transfers – the authorization must be obtained by the transferring physician/dentist no later than the next business day, or by the receiving physician/dentist or hospital before discharge.

If the transfer is approved, a PACER number is issued. The receiving hospital must use this PACER number when billing. The transferring hospital continues to use the original PACER number if a PACER number was required for the admission.

Monday, August 7, 2017

Top 50 Billing Error Reason Codes With Common Resolutions


Description Common Resolutions 

0453 Enrolled in HMO or an Encounter Claim for F. F. S. Verify the enrollee eligibility and bill the claim to the appropriate
carrier.

0302 Duplicate of History File Record, Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittance to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remit with the denied claim


0301 Duplicate Payment Request-Same Provider, Same Dates of Service Provider has already received payment for this date of service. Review your prior remittances to identify the payment, which has already been made. If you can’t locate the previous payment call the Provider Helpline *Note- make sure the prior remittance’s provider number matches the number of the remittance with the denied claim

0318 Enrollee not eligible on DOS Claim will deny if the client is not eligible during dates of service billed. Check enrollee eligibility status through MediCall to verify eligibility on the date of service being rendered. If the enrollee is not eligible no payment will be received from Virginia Medicaid. If upon verification you find that the client is now eligible on that date of service resubmit the claim.

1393 No Srvc Taxonomy Code on the Claim Verify that the servicing provider taxonomy code was on the claim.

0309 Services Not Covered Verify the client’s eligibility on our Medicall system. If the client is eligible, contact the Provider Helpline to verify that the client is enrolled in the program for which services were billed.

0313 Enrollee is covered by private insurance, refer to third party information of this R/A

Our system indicates that there is a primary carrier, which needs to be billed prior to Medicaid. This carrier is now listed on your remittance advice under the claims information for that particular client. Please refer to this other coverage information which should be billed as primary.

*NOTE: If the client states there is no other coverage then they will need to contact their case worker at the Department of Social Services to have this information corrected

0732 Servicing Provider Invalid Verify the 10 digit number entered for the servicing provider.

0155 Procedure Requires Authorization The procedure/revenue code billed requires a preauthorization and there is no PA number on the claim. You must get preauthorization from the appropriate area depending on the service being provided. The preauthorization number received is required on the claim.

0039 Qualified Medicare Beneficiary Only Enrollee. Medicaid coverage limited to deductible and coinsurance.

Qualified Medicare Beneficiary (QMB) Only clients are eligible only for payment of Medicare premiums, deductibles, and coinsurance. If a QMB Only claim is denied by Medicare then there will be no reimbursement by Medicaid.

0983 Enrollee Not on File Verify the enrollee’s Medicaid ID number.

0456 Enrollee Not Covered for this ServiceVerify the enrollee is covered for the service you are billing.

0485 Authorization by Medallion PCP Not Indicated The members primary care provider must authorize services

0308 Your payment request was filedpast the filing time limit without acceptable documentation

Virginia Medicaid is mandated by federal regulations to require the initial submission of all claims (including accident cases) within 12 months from the date of service. Medicaid is not authorized to make payment on claims submitted after the 12 month timely filing limit, except under the conditions listed in the Providers Manual Chapter V pgs 2-3. For additional details regarding the timely filing regulations, please reference the appropriate Provider Manual, Chapter 5 0022 Servicing Provider is Not Eligible to Bill this Payment Request Type

The servicing provider billed on the claim is not eligible to bill this claim.

1357 NPI Servicing Provider Not on File

Verify the 10 digit NPI entered for the servicing provider.

0385 Re-bill on Title XVIII Invoice If the claim is being submitted to Medicaid for deductible and coinsurance secondary to Medicare’s payment, and the claim to Medicare was submitted in a CMS-1500 format, then the claim to Medicaid must be submitted on a Title XVIII claim format.

0028 Admit Date Missing or Invalid UB 04–. The admit date must be numeric without any dashes or slashes.

0367 This enrollee is covered by Medicare part B, Rebill on Title 18 Medicaid requires claims be submitted on a Title 18 for Medicare Part B deductible and coinsurance. See Medicaid Memo dated 3/18/04.

0161 Authorization Not Valid for Dates of Service

The payment request's from and thru dates of service must fall within the PA's begin and end dates. CMS – 1500 and UB-04: Please verify the correct PA number was entered.

0731 Servicing Provider Not Eligible on DOS

The servicing provider was not eligible on the date of service. Contact Provider Enrollment Unit.

0370 Wrong Procedure Code Billed Check your claim to verify that the correct/valid procedure code was billed, if you feel the code is correct call the Provider Helpline to verify the code billed

0757 Servicing Provider Can Not be a Group Provider

The servicing provider number used on your claim can’t be a group NPI number.

0756 Billing Provider is not a Group Provider

The billing provider must be enrolled as a group provider. Contact Provider Enrollment

0730 Servicing Provider Not a Member of the Group

The servicing provider is not a member of the group provider, Contact Provider Enrollment

0480 Not CLIA Certified to perform procedure

Check that the CLIA number used on the claim is certified to perform the procedure.

0129 Revenue Code Not Covered UB 04 – Verify that the revenue code being billed is valid for the provider type and service

0026 Covered Days Missing or Invalid

UB 04 – Value code 80, enter the number of covered days for inpatient hospitalization or the number of days for re-occurring out-patient claims. The format for value code is digit: do not format the number of covered or non-covered days as dollar and cents.

0004 Enrollee ID Missing or Not in Valid Format

Verify the enrollee number for eligibility. The twelve digit enrollee number should appear as it is on the Medicaid Card.
0734 Covered Days Entered is greater than the Statement Period The covered days entered cannot exceed the difference between the from and thru dates.

1370 Invalid Present on Admission Flag

This requirement only applies to inpatient facility claims. The locator for the POA is right after the diagnosis code. A POA indicator is required for the primary, secondary and the external reason code. Review all diagnosis codes on the claim to assure the POA indicator was used. For more detail, please refer to the Hospital Manual, Chapter 5


0157 Approved Authorization Not on File The procedure billed requires authorization and the authorization is not on file. Verify that the authorization number on the claim is the correct authorization for the service billed.

0162 Number of procedures exceeds number authorized The number of units or visits billed is greater than the number of units or visits authorized on the PA

0191 Provider Referral Required The procedure code entered on the CMS-1500 or the revenue code on the UB-04 requires a referral, Verify the correct provider number is entered correctly on the claim.

0178 Invalid Diagnosis Code The primary diagnosis is not valid. Please verify that the diagnosis code is valid and is in the correct format.

0179 Invalid Discharge Status for Type Bill UB-04 –Enter the code indicating the disposition or discharge status of
the patient at the end service for the period covered on this bill (If the third position of type of bill is 2 or 3 the discharge status should be 30. If the third position of type of bill is 1 or 4 the discharge status should not be 30.

0014 Billed Amount Missing or Invalid CMS-1500 – Billed charges should be on each line. Do not use a decimal point.

UB-04 – The billed charges must be numeric without spaces.

0017 Missing Former Reference Number The original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim must be provided.

0055 The Type of Bill Missing or Invalid UB 04 –Type of Bill - Enter the code as appropriate

0077 Adjustment Denied - Original Payment Request Already Adjusted/Voided

An adjustment or void request cannot be submitted for a payment that has been previously adjusted or voided.

0110 Diagnosis Code Does Not Agree with Age The diagnosis given is not compatible with the enrollee's age.

0119 Service Period Not Equal Accommodation Days UB 04 - If a revenue code(s) is billed for accommodation or room and
board, the service units billed for the revenue code(s) must be equal to the number of days covered by the from-thru dates of service for the payment request.

0158 Enrollee Disagrees with Authorization

The authorization number used on the claim is not for the same enrollee as billed.

0160 Procedure Disagrees with Authorization The procedure billed on the claim is not the same procedure that has been authorized.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim
previously denied, you must submit the claim as a new c laim.

0364 Primary carrier payment equals or exceeds DMAS’ allowed amount The claim was submitted with COB code indicating there was a primary carrier which paid on this claim and that the primary carrier’s payment to you equaled or exceeded Medicaid’s allowed amount. DMAS will not reimburse you if the primary carrier payment exceeds the Medicaid allowed amount.

0035 Missing/Invalid Type of Accommodation Code UB 92 –,Enter the total number of covered accommodation days or
ancillary units of service where appropriate. Th s number is equal to the number of covered days.

0352 Only Paid Payment Requests Can be Adjusted/Voided Only paid payment requests can be adjusted or voided. If the claim previously denied, you must submit the claim as a new claim.

0015 Primary Carrier Pay Missing or Invalid

CMS-1500 – our records show there is a primary carrier and no TPLinformation is on the claim.

UB-04: if claim was submitted with a COB code of ‘83’ (primary carrier billed and paid) under ‘code’, the payment made by the primary carrier must be under ‘amount.”


Thursday, May 4, 2017

CPT code 80156, 80157 and 80184, 80185

Measure Name: Annual Monitoring of Anticonvulsant, Carbamazepine

Rule Description:

1) The percentage of patients 18 years and older who received at least 180 days of carbamazepine therapy and had at least one therapeutic monitoring event during the measurement year.

2) The percentage of patients 18 years and older who received at least 180 days of phenobarbital therapy and had at least one therapeutic monitoring event during the measurement year.

3) The percentage of patients 18 years and older who received at least 180 days of phenytoin therapy and had at least one therapeutic monitoring event during the measurement year.

4) The percentage of patients 18 years and older who received at least 180 days of valproic acid therapy and had at least one therapeutic monitoring event during the measurement year.

General Criteria Summary

1. Continuous enrollment: 1year
2. Anchor date: 31st  December of the measurement year
3. Gaps in enrollment: One 45-day gap allowed in each year of continuous enrollment
4. Medical coverage: Yes
5. Drug coverage: Yes
6. Attribution time frame: 1 year
7. Exclusions apply: Yes
8. Age range: 18 years and older



Note: Four separate denominator measures are being created because each subset used in a measure has to reference a specific rule.  It would be confusing to customers if we had measures that referred to rules that seemed unrelated. Therefore, there are separate subset and measure specifications for each Annual Monitoring denominator, even though the calculation of each denominator is exactly the same.

Denominator Description: All patients aged 18 years and older who received at least 180 treatment days of ambulatory anticonvulsant medication therapy during the measurement year

Inclusion Criteria: Patients aged 18 years and older as of the end of the measurement year who received at least 180 treatment days of ambulatory anticonvulsant medication therapy during the measurement year.  The four types of anticonvulsants checked are carbamazepine, phenobarbital, phenytoin, and valproic acid.



CPT  Description: Drug serum concentration for carbamazepine

80156 Carbamazepine; total
80157 Carbamazepine; free

LOINC
Description: Drug serum concentration for carbamazepine
3432-2 Drug serum concentration for carbamazepine
3433-0 Drug serum concentration for carbamazepine
9415-1 Drug serum concentration for carbamazepine
14056-6 Drug serum concentration for carbamazepine
14639-9 Drug serum concentration for carbamazepine
18270-9 Drug serum concentration for carbamazepine
29147-6 Drug serum concentration for carbamazepine
29148-4 Drug serum concentration for carbamazepine
32058-0 Drug serum concentration for carbamazepine
32852-6 Drug serum concentration for carbamazepine
47097-1 Drug serum concentration for carbamazepine

CPT Description: Drug serum concentration for phenobarbital
80184 Phenobarbital

LOINC Description: Drug serum concentration for phenobarbital
3948-7 Drug serum concentration for phenobarbital
3951-1 Drug serum concentration for phenobarbital
10547-8 Drug serum concentration for phenobarbital
14874-2 Drug serum concentration for phenobarbital
34365-7 Drug serum concentration for phenobarbital

CPT Description: Drug serum concentration for phenytoin
80185 Phenytoin; total
80186 Phenytoin; free

LOINC Description: Drug serum concentration for phenytoin
3968-5 Drug serum concentration for phenytoin
3969-3 Drug serum concentration for phenytoin
14877-5 Drug serum concentration for phenytoin
32109-1 Drug serum concentration for phenytoin

40460-8 Drug serum concentration for phenytoin

CPT Description: Drug serum concentration for valproic acid
80164 Dipropylacetic acid (valproic acid)


LOINC Description: Drug serum concentration for valproic acid
4086-5 Drug serum concentration for valproic acid
4087-3 Drug serum concentration for valproic acid
4088-1 Drug serum concentration for valproic acid
14946-8 Drug serum concentration for valproic acid
18489-5 Drug serum concentration for valproic acid
21590-5 Drug serum concentration for valproic acid
32119-0 Drug serum concentration for valproic acid
32283-4 Drug serum concentration for valproic acid

Thursday, April 27, 2017

CO 226 , MA 81, N455 Denial codes


CERT Signature Denials


Denial Reason, Reason/Remark Code(s)

CO-226: Information from the billing/rendering provider was not provided or was insufficient/incomplete

MA81: Missing/incomplete/invalid provider/supplier signature

Resolution/Resources:

The CERT review contractor assesses errors when signatures in practitioners’ medical records, including X-ray reports and orders, do not meet Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within 120 days of the date shown on the remittance advice notice of the denied services.  

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal with Palmetto GBA.

Please clearly indicate 'CERT' when completing the redetermination form


Absence of Valid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N455: Missing physician order

Incomplete/Invalid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N456: Incomplete/invalid physician order

Resolution/Resources

The CERT Review Contractor assesses errors when there is no evidence of 'intent' or documentation of the request, in accordance with Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers. For denial purposes, these messages will be applied in situations involving ordering-treating physicians or qualified non-physician practitioners.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within
120 days of the date shown on the remittance advice notice of the denied services.

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal.

Please clearly indicate 'CERT' when completing the redetermination form


Thursday, March 23, 2017

primary paid more than secondary allowed - Denial

0364 Primary carrier payment equals or exceeds DMAS’ allowed amount

The claim was submitted with COB code indicating there was a primary carrier which paid on this claim and that the primary carrier’s payment to you equaled or exceeded Medicaid’s allowed amount. DMAS will not reimburse you if the primary carrier payment exceeds the Medicaid allowed amount.


0017 Missing Former Reference Number

The original Internal Control Number (ICN) for claims that are being submitted to adjust or void the original PAID claim must be provided.


0077  Adjustment Denied - Original Payment Request Already  Adjusted/Voided

An adjustment or void request cannot be submitted for a payment that has been previously adjusted or voided.

0015 primary Carrier Pay Missing or Invalid

CMS-1500 – our records show there is a primary carrier and no TPL information is on the claim.
UB-04: if claim was submitted with a COB code of ‘83’ (primary carrier billed and paid) under ‘code’, the payment made by the primary carrier must be under ‘amount.”

0352  only Paid Payment Requests Can be Adjusted/Voided

Only paid payment requests can be adjusted or voided. If the claim previously denied, you must submit the claim as a new claim.

0014 Billed Amount Missing or Invalid

CMS-1500 – Billed charges should be on each line. Do not use a decimal point.
UB-04 – The billed charges must be numeric without spaces.

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