National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Reasons for Provider Notification of Medicare Claims Disputed/Rejected by Supplemental Payers/Insurers

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries (FI), Medicare Administrative Contractors (A/B MAC), and durable medical equipment MACs (DME MAC).

Provider Action Needed
Effective for claims processed on or after July 1, 2007, when claims crossed over by Medicare to a supplemental payer/insurer are rejected or disputed by that insurer, Medicare will add a standardized message to the notification to the provider. That message will be in the form of a Dispute Reason Code, which will explain why the supplemental insurer disputed the claim. Be sure your billing staff is aware of these codes, as described later in this article, and is ready to take corrective action, as appropriate.

Background
In MLN Matters article, MM3709, the Centers for Medicare & Medicaid Services (CMS) describes the notification process to Medicare providers when Medicare claims that should automatically cross to a supplemental payer/insurer-are not crossed over due to claim data errors. The notification is mailed to the correspondence address that is submitted by the provider, along with all other Medicare enrollment data, and is maintained by CMS’s Medicare contractors. (MM3709 may be referenced at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3709.pdf on the CMS Web site.)

There are also situations where provider notifications are sent after the claim has crossed to the supplemental payer/insurer. This occurs in situations where the insurer may not be able to process the Medicare claim for supplemental payment and, therefore, rejects or disputes the claim back to CMS’ Coordination of Benefits Contractor (COBC). When these situations occur, the COBC transmits a report containing the “disputed” claims to the Medicare contractor, which then notifies the provider, through a special automated correspondence, that the claim was not crossed automatically.

Beginning in July 2007, provider notifications will include standardized language for claims that have been disputed by the supplemental payer/insurer and the dispute has been accepted by the COBC. The standardized language will read: “Claim rejected by other insurer,” and it will include a reason code. The following is a list of the reason codes that may be contained in the standardized language and the definition of each:

Dispute Reason Codes:
000100 - Duplicate Claim
000110 - Duplicate Claim (within the same ISA – IEA loop)
000120 - Duplicate claim (within the same ST-SE loop)
000200 – Claim for Provider ID/State should have been excluded
000300 - Beneficiary not on eligibility file
000400 - Reserved for future use
000500 - Incorrect claim count
000600 - Claim does not meet selection criteria
000700 - HIPAA Error
009999 – Other

When Medicare providers receive this notification, they may need to take appropriate action to obtain payment from the supplemental payer/insurer for all Dispute Reason Codes except for 000100, 000110, 000120, and 000400.  

Additional Information
If you have any questions, please contact your carrier, FI, A/B MAC, or DME MAC at their toll-free number found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: SE0728
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A

News Flash - Rejected Claims Reminder
Fee-for-Service Medicare claims can be rejected by Medicare contractors (carriers, intermediaries (FIs), and Medicare Administrative Contractors (MACs)) for a variety of reasons including: incorrect billing information, terminated provider, the beneficiary is not eligible for Medicare or the claim was sent to the wrong contractor. If a provider has questions about a claim rejected by an FI/carrier or MAC, the provider should contact the contractor directly. It is never appropriate to direct the beneficiary who received the service billed on the claim to the 1-800-Medicare toll free line to resolve a claim rejection.