Currently, after A/B Medicare Administrative Contractors (MACs), Durable
Medical Equipment MACs (DME MACs), fiscal intermediaries (FIs), and carriers
have finalized payment of incoming provider/physician/supplier claims, they
transmit the adjudicated claims to the Coordination of Benefits Contractor
(COBC) for Medicare claims crossover purposes. The COBC translates the claims
into the required HIPAA ANSI 837 claim formats for claims crossover purposes,
then subjects them to HIPAA compliance validation; normally, it is within this
module that HIPAA compliance problems are identified.
When the COBC identifies HIPAA compliance problems, it notifies the A/B MAC,
DME MAC, FI, or carrier that its processed claims could not be crossed over.
This entity, in turn, mails the affected provider/physician/or supplier a
special letter that indicates "The claim(s) could not be crossed over due to
claim data errors..." and includes the specific error code (eg. H51000) with
accompanying error description. The assumption is that once
providers/physicians/suppliers receive these letters from Medicare, they will
then take steps to bill their patients' supplemental payer for the balances
owed after Medicare.
In recent weeks, three issues have arisen that were caused by defects in the
COBC compliance validation process:
§ H51108: '237' is not a valid 'Line Level Adjustment Reason Code'
o Issue: COBC was incorrectly rejecting claims that contained a claim
adjustment reason code (CARC) 237. The rejection occurred because COBC's
vendor inadvertently did not have reason code 237 loaded to its CARC table.
o Fix date: Mon Jan 16
§ H20203: Element CLM16 is present though marked 'Not Used'
o Issue: COBC's vendor's translation routine was copying the value from 2300
CLM20 and incorrectly creating that value within 2300 CLM16 ('Not Used')
o Projected fix date: Mon Feb 27
o Steps taken: As of the week of Mon Feb 13, CMS asked its A/B MACs, DME
MACs, FIs, and carriers to hold the letters they would normally generate that
contain error code H20203. Effective Mon Feb 27, our Medicare contractors will
be able to resend the affected claims to the COBC so that they may be
successfully crossed over.
§ H45255: The Other Subscriber Primary Identifier (2330A NM109) cannot be the
same as the group or policy number (2320 SBR03)
o Resolution: COBC scrubs the duplication that is present in 2320 SBR03
o Project fix date: TBD, but hopefully not later than early April 2012
o NOTE: Currently, error H45255 is prohibiting the sending of Medicare
crossover claims to North Dakota Medicaid in certain instances.
o Steps taken: CMS is requesting that Medicare contractors hold the letters
that would normally be generated for error code H45255. Once a fix date is
identified for this issue, CMS will notify the Medicare contractors to resend
the affected claims to the COBC so that they may be successfully crossed over.
CMS sincerely regrets that the above error conditions have arisen. We are
actively partnering with the COBC to address these problems as quickly as
possible.
________________________________
It's Not too Late to Give and Get the Flu Vaccine. Take advantage of each
office visit and protect your patients against the seasonal flu. Medicare will
continue to pay for the seasonal flu vaccine and its administration for all
Medicare beneficiaries through the entire flu season. The Centers for Disease
Control and Prevention (CDC) also recommends that patients, healthcare workers
and caregivers be vaccinated against the seasonal flu. Protect your patients.
Protect your family. Protect yourself. Get the Flu Vaccine-Not the Flu.
Remember - The flu vaccine plus its administration are covered Part B benefits.
CMS has posted the 2011-2012 seasonal flu vaccine payment limits at
http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp. Note that
the flu vaccine is NOT a Part D-covered drug.
For more information on coverage and billing of the flu vaccine and its
administration, as well as related educational provider resources, visit
http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp and
http://www.cms.gov/immunizations.
________________________________
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Please DO NOT respond to this email. This email is a service of CMS and routed
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