Noridian Identifies Top 5 Claim Submission Errors

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  • November 2, 2009
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Want to increase the number of claims that successfully complete processing and enhance a positive cash flow? Heed Noridian Administrative Services’ (NAS) advice. The Medicare administrative contractor (B/MAC) has identified its top five denials for the months of July, August, and September and offers solutions and resources.

1. These are non-covered services because this is not deemed a “medical necessity” by the payer.

Under the Medicare program, a service is medically necessary if it is “needed for the diagnosis or treatment of your medical condition, meet[s] the standards of good medical practice in the local area, and is not mainly for the convenience of you or your doctor.”

2. Claim denied as patient cannot be identified as our insured.

The most reliable means of obtaining a patient’s correct Health Insurance Claim Number (HICN) number and correct name is to copy this information from their red, white, and blue Medicare card.

Common situations that can cause an unprocessable denial:

  • Spaces, hyphens, transposition, or incorrect suffix in HICN. (If the Medicare card or the national file shows hyphens, the beneficiary should contact SSA.)
  • Incorrect spelling or transposition of first and/or last name. (The name on claim must match the name on the Medicare card, including suffix, if applicable; nicknames are not accepted.)
  • Middle initial in the first or last name field when filing electronically.

3. Claim lacks the National Provider Identifier (NPI) of the ordering/referring or performing physician, or practitioner, or the NPI is invalid.

Certain services and situations require the submission of the referring/ordering physician information. (For details, see the CMS-1500 instructions.) In such cases, two pieces of information are necessary. If either is missing, invalid, or incomplete, an unprocessable claim denial will occur.

MLN Matters 6417 indicates these requirements:

  1. Referring/ordering provider’s name in item 17 on the CMS-1500 paper form or the electronic equivalent, which must be listed last name, first name.
  2. Referring/ordering provider’s NPI in item 17b on the CMS-1500 form or the electronic equivalent.

4. Benefit maximum for this time period or occurrence has been reached.

In certain circumstances, frequency or financial limitations have been placed on particular Medicare beneficiary services/procedures. If the limit is exceeded, the service/procedure will deny.
Common reasons for such denials:

Preventive services: Be sure to review the patient’s records prior to performing these services to ensure medical necessity:

  • Initial Preventive Physical Examination (IPPE)
  • Adult Immunization: Influenza Immunization, Pneumococcal Vaccination, Hepatitis B Vaccination
  • Colorectal Cancer Screening
  • Screening Mammography
  • Screening Pap Test and Pelvic Examination
  • Prostate Cancer Screening
  • Cardiovascular Disease Screening
  • Diabetes Screening
  • Glaucoma Screening
  • Bone Mass Measurement
  • Diabetes Self-Management, Supplies, and Services
  • Medical Nutrition Therapy
  • Smoking Cessation

Quick Reference Information:

Medicare Preventive Services – This is a Centers for Medicare & Medicaid Services (CMS) reference chart located on the CMS Web site. It provides Medicare fee-for-service physicians, providers, suppliers, and other health care professionals a quick reference to Medicare’s preventive services.

The Guide to Medicare Preventive Services – This CMS guide provides information on Medicare’s preventive benefits including coverage, frequency, risk factors, billing, and reimbursement.

Outpatient Therapy Cap: The annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1,840; and the separate limit for occupational therapy is $1,840.

5. Did not complete or enter accurately the CLIA number.

The Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations require a facility to be appropriately certified for each test they perform. Laboratory claims are currently edited at the CLIA certificate level to ensure CMS only pays for laboratory tests categorized as waived complexity under CLIA (for facilities with a CLIA certificate of waiver).

If applicable, the 10-digit CLIA certification number for laboratory services billed by an entity performing CLIA covered procedures in item 23 of the CMS-1500 claim form or its electronic equivalent. An overview of the CMS CLIA program is available on the CMS Web site.

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