Reason Code 34963 - JE Part A

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

• MLN Matters Article 12889