Top Medicare Claim mistakes

Navigating the complex and ever-evolving world of Medicare claims can sometimes be scary and defiantly frustrating. After hours of pouring over a new claim file and submitting it electronically, you are hit with the dreaded 277 and or 999 file rejection. Well, hopefully, this article can save you some time as we will go over a few of the most common reasons for a Medicare claim rejection.

Let’s start with some of the more common claim errors

Duplicate Claim for service

Basically, this means you or one of your billers have submitted a claim either electronically or by paper for a service provided by the same physician to the same beneficiary and the same date. This can often happen when an office is very busy. One biller may think they are the ones in charge of filling a claim and another may have already sent that claim file off. The second claim will be automatically denied as a duplicate.

Some may see this as not a big deal. However, if your billers continue to resubmit duplicate claims you run the risk of the Medicare system identify your doctor as an abusive biller.

Duplicate claims will often contain the same :


Claim not sent on time

We all now things can get hectic in an office or dealing with dozens of Medicare claims that need to be sent. But we often see claims coming back denied for this reason. If you have not already done so, please save yourself and your team a big avoidable headache and set up a system to make sure claims are being sent out on time.

Physician’s primary identifier is missing or invalid

This one is another simple but often fount claim mistake. Not making sure to put the referring physician’s National Provider Identifier (NPI) will get your claim rejected. So please make sure to include it on the CMS-1500 form in section 17b

CMS 1500 claim file

Incorrect patient identifier information

We all know someone who uses their middle name as their first name or goes by a shorten name like Mike instead of Micheal. However, if you input any name other than what is on the patient’s Social security number you will get a claim denial. A good rule of thumb is to simply verify the patient’s full name and let them know you need what is on their social security card.

Claim not covered by this payer/contractor

Sending a Medicare claim to the wrong Medicare administrative contractor (MAC) is a quick way to get automatically denied. You must make sure you are sending the patient's claim to the correct MAC. Here is a quick list to help you know which MAC covers which area

Home Health agencies

One of the biggest MAC’s Palmetto GBA has released some interesting data relating to Home Health denial codes.

Here are the top 5 Home Health denial codes and how to resolve them

Reason code 31947

This claim line was submitted by the provider as non-covered. Providers must use a specific modifier or indicator on the claim attaches liability to the beneficiary.

How to resolve:

Use one of the following condition codes:

  1. OC 32 = Advance Beneficiary Notice (ABN) given; report with appropriate liability-related modifier and covered charges

  2. CC 20 = Demand bill will be reviewed

  3. CC 21 = No-payment, automatically process

Reason code 38157

FISS Narrative This RAP is a duplicate of a paid RAP or paid, suspended or denied home health claim for the same provider number, patient's Medicare ID number and statement 'From' date but without a cancel date

How to resolve:

When using batch file transfer software, have an internal procedure in place to ensure batches of billing transactions are deleted from the software once they are submitted to Medicare. Also, review Medicare Remittance Advice timely, monitor the status of your RAPs and claims through DDE, and stay current in posting payments received from Medicare. Do not resubmit an identical billing transaction if you have already corrected the RAP or claim from the Return to Provider (RTP) file.

Reason code U5200

The CMS records indicate that the beneficiary is not entitled to Medicare coverage for this type of service billed on the claim. Therefore, no Medicare payment can be made.

How to resolve:

The purpose of this edit is to ensure that Medicare pays only for services for which the beneficiary is entitled. The CMS records indicate that the beneficiary is not entitled to Medicare coverage for the type of service billed on the claim, therefore; no Medicare payment can be made. Investigate and check the patient’s eligibility. If appropriate, correct and resubmit the claim.