CMS Offers 496 Edit Resolution

In the Medicare FFS Provider e-News for Feb. 22, under the Claims, Pricer and Code Updates heading, is a so-called “resolution” from the Centers for Medicare & Medicaid Services (CMS) for providers receiving the 496 edit on electronically filed claims using the new 5010 transaction standard. According to CMS, since the implementation of Version 5010 on Jan. 1, the number of billers receiving the 496 edit has increased considerably.

The 496 edit is commonly referred to as a “linkage problem” because it generally indicates a linkage issue between provider and clearinghouse/vendor in Medicare’s system that simply needs to be updated. It can also indicate a billing error, however.

CMS recommends billers evaluate their Health Care Claims Acknowledgement message (277CA), and all additional edits incurred as a result of a 496 edit, before calling their Medicare administrative contractor (MAC).

The 277CA will have the following message components in the Status Segment related to a 496 edit:

  • First part: Claim Status Category Code = “A8” – Acknowledgement/Rejected for relational field error
  • Second part: Claim Status Code = “496” – Submitter not approved for electronic claim submissions on behalf of this entity
  • Third part: Entity Identifier Code = “85” – Billing Provider

The message “A8:496:85” means the claim was rejected for a relationship error between the submitter and the billing provider. A billing error of this nature may occur if the rendering provider’s National Provider Identifier (NPI) is inappropriately being used instead of the billing provider’s or group’s NPI. This type of error is remedied easily enough, but time is of the essence. Remember: Mandatory 5010 compliance begins March 31.

Also in this issue, CMS offers fee-for-service (FFS) providers the usual reminders of upcoming national provider calls and other calls, meetings, and events. There are also a few announcements, reminders, and updates that may be of interest to you, such as the February release of a new  Short-term Acute Care Program for Evaluation Payment Patterns Electronic Report (ST PEPPER) and a revised “Tobacco-use Cessation Counseling Services” brochure.

Read the Feb. 22 issue of CMS Medicare FFS Provider e-News for further details regarding the 496 edit, and for other information pertaining to Medicare Part B services.

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