Reason
Codes |
FISS Narrative |
Explanation and Suggestions |
| 38107 |
A HH final (TOB 329 or 339) is being processed and a HH rap (TOB 322 or 332) does not exist.
-or -------
One of the following fields on the final (TOB 329 or 339) do not match to the RAP
1) statement from date
2) admission date
3) HIPPS code
4) line item date for the HIPPS code (0023 revenue line date)
5) provider number |
The system cannot find a processed RAP that corresponds to the Final claim: This could occur when:
- No RAP has been submitted, or
- Your processed RAP auto-canceled due to untimely filing of the Final claim (60 days from paid date of the RAP or 120 days from the start of care).
- The processed RAP has fields which do not match the fields in your Final claim
Verify in the Direct Data Entry (DDE) system if there is a processed RAP.
- If there is not a RAP in the system, bill the RAP. When the RAP posts to the Common Working File (CWF):
a. In DDE, select 03 Corrections, access the RTP’d Final claim and F9 the claim.
- If there is a RAP, does it show a cancel date? This could mean that the RAP was auto-canceled (in CWF the episode will show a patient indicator 1). If the RAP was canceled you need to resubmit the RAP.
- If there is a processed RAP, ensure that the RAP and Final claim information match in these fields:
1. Statement FROM Date
2. Admission Date
3. HIPPS Code
4. 0023 Revenue Code line
5. Item Service Date (Field 45)
- If the RAP information is correct make the necessary changes on the Final claim in ‘T’ status and F9 the claim.
- If the Final claim information is correct, cancel the processed RAP. Once this processes, re-submit a new RAP with information that matches the Final claim.
|
| 32403 |
According to the revenue code table, a HCPC is required for the line item being edited; however, the statement coverage dates on the claim fall outside of the effective/termination dates for the HCPC on the HCPC table file, so the HCPC was not valid during the statement coverage period.
this edit is bypassed when:
- HH TOB 32x or 33x
- statement from date >= 01/01/2007 and < 01/01/2008
- statement to date >= 01/01/2008
- valid 2007 HIPPS code (haej1 - hdim8)
HIPPS code dos <= HIPPS code term date |
This claim has been returned because a HCPCS code has been reported in Form Locator 50 which is not valid. The HCPCS Code is invalid because the service date reported in Form Locator 22 is prior to the date the HCPCS Code became effective, or, is on or after the date the HCPCS Code was deleted from the list of valid codes. Please correct and resubmit/rekey the hardcopy submittors resubmit RTP Report with corrections (I.E. Outpatient Claim with DOS 01/01/92 or after With HCPCS 90000, or DOS before 10/16/91 With HCPCS Q0086, or DOS 03/01/91 or after With HCPCS 80067). |
| C7273 |
An incorrect HIPPS was billed on this rap. History shows there was an inpatient stay within 14 days of a home health admission. Please correct and resubmit. |
The HIPPS code does not show there was an Inpatient stay within 14 days of the home health admission. However, an Inpatient stay is in the claims history file.
Verify HIPPS code based on the OASIS information (M0175).
Make the necessary corrections to the RAP in “T” status and F9 to update. |
| 30720 |
For episodes prior to 01/01/2008, this reason code is assigned for home health type of bills 3x2 or 3x9. The treatment authorization code is not present or is not valid. The valid format for home health type of bills is eighteen numerics.
For episodes 01/01/2008 or after, this reason code is assigned for home health type of bills 3x2, 3x9, 3x7, or 3x(alpha) for adjustments. The treatment authorization code is not present or is not valid, and condition code 21 is not present. The treatment authorization code is valid if in the following format:
§ Position 1 and 2 = numeric
§ Position 3 and 4 = alpha
§ Position 5 and 6 = numeric
§ Position 7 and 8 = alpha
§ Position 9 = numeric
§ Position 10 = 1 or 2
§ Position 11 - 18 = alpha |
This reason code is assigned for home health Type Of Bills 3X2 3X9.
The Treatment Authorization code is not present or is not valid.
The valid format for home health type of bills is eighteen numerics for service dates beginning on or before January 1, 2008.The valid format for service dates beginning on or after January 1, 2008 is as follows:
§ Position 1 AND 2 = NUMERIC
§ Position 3 AND 4 = ALPHA
§ Position 5 AND 6 = NUMERIC
§ Position 7 AND 8 = ALPHA
§ Position 9 = NUMERIC
§ Position 10 = 1 OR 2
§ Position 11 - 18 = ALPHA
Please check to ensure that the claim was submitted with the correct format. If not, correct and resubmit the claim. |
| 32116 |
The receipt date of the claim is on or after the NPI implementation date in the system control file and the billing provider NPI is not present on the claim.
*will not assign when the demo code is '31'. |
The receipt date of the claim is on or after the NPI The implementation date in the system control file and the billing provider NPI is not present on the claim. |
| N5052 |
Beneficiary identification incorrect: the beneficiary name and or other personal data in the CWF transaction did not match the data stored on the beneficiary master record. |
The beneficiary’s identification is incorrect or the Health Insurance Claim Number is not on the Master File.
Verify the information on the beneficiary’s Medicare Card or check the HIQA for exact spelling of name and Jr/Sr information.
Make necessary corrections and F9 claim.
It may be necessary to contact the beneficiary for further verification |
| NT010 |
For intermediary use only; no provider action is required |
This code indicates a system issue. Providers should first refer to the Palmetto GBA “Claims Processing Issues” at www.PalmettoGBA.com/rhhi
In addition, providers may contact the Provider Contact Center (PCC) at: 866-801-5301 |
| T5052 |
CMS records indicate the beneficiary is not on file. Verify the beneficiary’s identification number and resubmit. |
This reason code is very similar to N5052. The beneficiary’s identification is incorrect or the Health Insurance Claim Number is not on the Master File. Therefore, the claim cannot process.
Verify the information on the beneficiary’s Medicare Card or check the HIQA for exact spelling of name and Jr/Sr information.
Make necessary corrections and F9 claim.
It may be necessary to contact the beneficiary for further verification. |
| 31755 |
This reason code will be assigned if home health type of bill 3x2 or 3x9 is entered and the following criteria is not a match:
If the admission date of the claim is equal to the statement from date, the earliest 0023 line date should also be equal;
Or
rev code 0023 was not found;
Or
If final, each 0023 service date must equal a visit service date for the 0023 span.
Effective for dos 07/01/01 and greater. |
The From and Thru Dates and Admission Date on the RAP are the same. Therefore, the 0023 line item Service Date must also match.
OR
The Final Claim does not have a visit that corresponds to the date shown on the 0023 line item Service Date (the first billable visit).
OR
The RAP is missing the revenue code 0023 and line item Service Date.
Review the RTP’d RAP in the Direct Data Entry (DDE) system.
- Does the Statement From and Thru Date (Field 6) match the Admission Date (Field 17)? If yes, select 03 Corrections in DDE, access the RAP and change the 0023 line item Service Date (Field 45) to the same date, F9 the claim.
- If 0023 line item Service Date is missing from the claim, it can be added and then F9 the claim.
Is there a visit on the final claim that matches the 0023 line item service date? If no, verify that the 0023 line item service date is correct (first billable visit). Select 03 Corrections in DDE, access RTP’d claim and add visit to the final claim, and correct total charges. If 0023 line item service date on the RAP is incorrect: Cancel the processed RAP. Once the processed RAP is canceled, resubmit a new RAP. |
| 32038 |
Claim is type of bill 32x or 33x with service dates of 10/01/97 or greater, and provider fiscal start date is equal to 10/01/97 or greater, a value code 61 is present with a value code amount (MSA code) that contains more than 4 positions (not including the decimal places) that represent the MSA code but the MSA code is either invalid or is not present on the MSA table.***
For claims with service through dates 01/01/06 or greater, a value code 61 is present with a value code amount that contains
More than 5 positions (not including the decimal places) that represent the CBSA code but the CBSA code is either invalid or is not present on the CBSA table. |
The claim bill type is equal to 32X OR 33X with date of service of 100197 or greater. Value code 61 is present with a value code amount that is either invalid or not present on the MSA Table.
Please correct and resubmit hardcopy. Submittors resubmit RTP report with corrections.
*****For Claims with service through dates of 010106 or greater, a Value code of 61 is present with a Value Code Amount (CBSA CODE) but the CBSA code is 1) either invalid or is not present on the CBSA table. |