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Claim Submission Billing, Errors and Solutions

Avoiding Denials on Priced Per Invoice Claims - Various procedure codes require pricing per invoice and must contain specific elements in Item 19 of the CMS-1500 claim form or its electronic equivalent for each line item submitted.

Incarceration Claim Denials - In the summer of 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated or in custody on the date of service. For these recoveries, CMS identified previously paid claims that contained a date of service that partially or fully overlaps a period when a beneficiary was apparently incarcerated based on information from the Social Security Administration. As a result, a number of overpayments were identified. View solution progression.

Maternity Services - View maternity coverage guidelines and billing instructions.

Modifier and HCPCS Changes - View the new and deleted National Level II modifiers and HCPCS.

Observation and Inpatient (E/M) Common Denials and Resolutions - View and search for common E/M denials with details about resolutions.

Provider Enrollment, Chain, and Ownership System (PECOS) - N264/N265 Denials - If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based PECOS or by completing the paper enrollment application (CMS-855O).

Reason Code Guidance - View the most common claim submission error codes, a description of the issue and potential solutions.

Routine Service Billing - If Medicare denies a service that is generally covered by Medicare as a routine service, providers are allowed to charge the patient their normal charged amount. However, you may not exceed the amount that was billed to Medicare on the claim for that service. See Section 1128(6)(A) of the Social Security Act This link will take you to an external website.

Unlisted Procedure and Not Otherwise Classified Codes - View claim submission requirements when billing unlisted procedure and Not Otherwise Classified Codes (NOC).


Last Updated Aug 17, 2017