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Thursday, January 29, 2015

Part A - Duplicate reject/return to provider (RTP) reason code and rejection code 76474


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 claim previously submitted.

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
• 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
You received the reason code due to one or more of the following items are matching on the 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) , you can access the beneficiary's HIC number to verify the history of claims you have 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) 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. If you submit your claims via the electronic data interchange (EDI) gateway pdf.gif, the EDI gateway provides you with confirmation of the batch of claims received. Please wait for this confirmation instead of resubmitting the batch of claims. If you make one change to one claim in the batch and resubmit the batch, all the claims in the batch 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. You may make updates by adjusting the original processed claim (TOB xx7).
2. You may cancel the original processed claim (TOB xx8), but must wait for the cancelled claim to finalize prior to submitting the corrections on a new claim.
• When two claims were submitted at the same time and duplicated against each other, you may submit a new claim.
• No action is required when the claim is an exact duplicate to a previously processed claim.

Avoiding reason code 76474 
Q: We are receiving reject reason code 76474, so what steps can we take to avoid this reason code?

Reason code: 76474
Description : OUTPATIENT PHYSICAL AND SLP THERAPY EXPENSE LIMIT OVER APPLIED. PT/SLP EXPENSE SUBMITTED IS GREATER THAN THE EXPENSE TO BE MET. TYPE OF BILL '12X' (EXCLUDING CAH PROVIDER RANGE 'XX1300-XX1399') AND '13X' WITH MODIFIER 'GN' OR 'GP' HAS BEEN ADDED TO THE EDI TING LOGIC FOR PT/SLP CAP EFFECTIVE FOR DATES OF SERVICE ON OR AFTER 10/01/2012 THROUGH 12/31/2012. -OR- PT/SLP ADJUSTMENT NECESSARY FOR MSP CLAIM.

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.



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