First Quarter Top Return to Provider (RTP) Claim Errors

The following summarizes the top Return to Provider (RTP) claim errors identified during the first quarter, highlighting common billing issues impacting claim processing and reimbursement. Understanding these frequent reason codes and associated errors will help providers improve claim accuracy, reduce RTP rates, and ensure timely payment by aligning billing practices with current CMS and Medicare Administrative Contractor (MAC) guidance.

Reason Code W7021- Critical Access Hospital (CAH) Method II claims, the claim contains a medical visit code assigned status indicator V or J2 on same DOS as procedure assigned status indicator “T” or “S” but modifier 25 not reported.

How to avoid or correct this error:

  • CR14288 January 2026 Integrated Outpatient Code Editor (I/OCE) Specifications Version 27.0
  • New Documentation: Sub section Medical Visit Processing for CAHs added to expand on visit logic applicable for edit 21
  • January 2026 Integrated Outpatient Code Editor - Refer to section 6.9 Medical Visit Processing for CAHs

Reason Code U5065 - MBI is invalid; Claim from date is prior to the MBI effective date on the CWF crosswalk File and the MBI is the oldest occurrence in the HICXWALK File for the Beneficiary at CWF.

Reason Code 34963 - Attending Physician on Claim Page 05 is invalid or not present in the PECOS Enrolled Physicians file, Type C Records or Attending Physician NPI is present on the PECOS Enrolled Physicians file, but the first four characters 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).

Reason Code 38105 - Whether any revenue code lines are equal or not, outpatient types of bill (13X, 14X, 83X, or 85X) cannot have overlapping dates when the provider numbers are equal unless:

  • One of the claims is for a Pap smear only
  • One of the claims is for mammography screening only
  • The outpatient claim has a span code 74, and the ASC claim has a date of service within the span code 74 dates
  • The 14X and 83X are from a Maryland waiver provider (MWI = Y), and the 14X contains lab only while the 83X does not contain labs
  • One of the claims is for repetitive Part B services only for CAH (85X) type of bill
Last Updated May 13 , 2026