Medicare denial - Benficiary not file and spouse working for the employer

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)


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?
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.

Q: We are receiving reject reason code 34538, so what steps can we take to avoid this reason code?
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.
• Users can access eligibility information via direct data entry (DDE) pdf.gif.
• Contact the interactive voice response (IVR) pdf.gif 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.
• Obtain the beneficiary’s eligibility via the SPOT (Secure Provider Online Tool).
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.
If the information is valid
File the claim to the primary insurance listed on the beneficiary’s records and then to Medicare for secondary payment consideration