MAC Gives Top Five EDI Reasons for Claim Rejections

Cahaba GBA posted in its April 2010 newsletter Medicare B Newsline the top five reasons electronic claims in each state under its jurisdiction were rejected in February. The Medicare Administrative Contractor’s (MAC) daily audit trails show which claims were accepted and rejected by the Part B processing system. Referring to these reports enables providers to correct and resubmit claims quickly, which will dramatically reduce turnaround time. You will also become aware of any major problems with your claims so they can be corrected before they create an interruption in your cash flow, Cahaba advises.

Although the top reasons for electronic data interchange (EDI) claims being rejected vary slightly in each state under Cahaba’s jurisdiction (Alabama, Georgia, Tennessee and Mississippi), there are certain rejection codes that appear across the board. Here are the most popular rejection codes that made the top five list for each state in jurisdiction 10.

1. 434 – PROC CODE REQUIRES REFERRING NPI

Procedure code billed was for a diagnostic procedure, such as an X-ray or lab, which requires the NPI [National Provider Identifier] of the ordering physician, or a consultation, which requires the NPI of the referring physician.

This error accounted for 7,906 claims being rejected in Georgia.

2. 421 – DIAG CODE (XXXXX) INVALID FOR DATE SVC

The diagnosis code submitted was invalid on the date of service billed.

This error accounted for 5,458 claims being rejected in Georgia. Alabama was the second runner up with 5,446 rejected claims.

3. 888 – INSTREAM REJECTION

There was a problem involving HIPPA required loops, segments, or values. The specific loop will be identified, for example, “ELEMENT N401 (D.E.19) AT COL. 4 IS MISSING, THOUGH MARKED ‘MUST BE USED’ (LOOP:2010BA POS:3140).” The number after “POS” indicates the position in the file where the error occurred.

This error accounted for 6,406 claims in Alabama being rejected.

4. 377 – PAID & ADJUSTMENT AMOUNTS DO NOT EQUAL CLAIM CHARG

The submitted claim was a Medicare Secondary Payer (MSP) claim, and the paid plus the adjustment amounts do not total the claim charged amount.

5. 480 – LINE PAID AMOUNT CANNOT BE GREATER THAN ALLOWED AM

The claim was billed as a Medicare Secondary Payer (MSP) claim and the primary paid amount for a line item on the claim was greater than the primary allowed amount, or the primary paid or allowed amount was missing.

View Cahaba’s April 2010 issue of Medicare B Newsline.

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