Reason Code 34963

The Attending Physician on Claim Page 05 is invalid or not present in the PECOS Enrolled Physicians file, Type C Records. Or the Attending Physician NPI is present on the PECOS Enrolled Physicians file but the first four digits of the last name do not match. Or the claim has a Through Date of Service equal or greater than the Termination Date on the PECOS Enrolled Physician Inquiry screen (MAP1B52).

Common Reason Code Errors

  • Claim submitted with an attending physician NPI number that is not valid in PECOS.
  • Claim submitted with a name not matching the first initial of the first name, and first four letters of the last name (common with maiden names and newly hyphenated names)
  • Claim submitted with an organizational NPIs in place of individual attending physicians NPI
  • Claim submitted with an NPI for a physician or non-physician practitioner specialties that is NOT eligible as an attending physician enrolled in PECOS in an approved status. Valid values are:
    • Doctor of medicine or osteopathy
    • Dental surgery (19)
    • Podiatric medicine (48)
    • Optometry (41)
    • Chiropractic medicine (35)
    • Physician assistant (97)
    • Certified clinical nurse specialist (89)
    • Nurse practitioner (50)
    • Clinical psychologist (68)
    • Certified nurse midwife (42)
    • Licensed clinical social worker (80)
    • Certified registered nurse anesthetist (43)
    • Registered dietitian/nutritional professional (71)

Common Reason Code Corrections

  • Verify that the attending provider NPI is enrolled in PECOS
  • Verify that the name attending provider Name is submitted on claims as listed in PECOS.
  • Verify that the attending physician NPI submitted is a valid specialty from the list above, and not a group or organizational NPI.

Resources

 

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