Top Five Reasons for Claim Rejections for December 2007 for Georgia Submitters

Audit trails show which of your claims were accepted by the Cahaba GBA Part B processing system, along with claims that were rejected and the reason for the rejection. Referring to this report will allow you to correct and resubmit claims quickly, resulting in a dramatically reduced turnaround time. You will also become aware of any major problems with your claims so they can be corrected before they create an interruption in your cash flow. Audit trail reports are available the next business day for files that are received before 4:30 p.m. Eastern Time. If you are not receiving your audit trails contact your software vendor, billing service, or clearing house.
In order to increase the number of claims that successfully pass through audit trails and into processing Cahaba GBA Part B EDI Services is providing you with the top five reasons for claim rejections. For the month of December 2007, these are:
209 INVALID LAST NAME FOR HIC NUMBER 14,871 claims
The last name submitted for the beneficiary does not match the last name we have on record for the HIC number on the claim. The beneficiary's last name must include apostrophes, spaces, hyphens, etc., if they appear in the beneficiary's last name on his or her Medicare card.
383 INVALID NPI/LEGACY MEDICARE PROVIDER NUMBER COMBIN 14,165 claims
The legacy provider number submitted in the indicated loop is not associated on our crosswalk with the NPI submitted. Be sure the NPI submitted is the correct NPI for the legacy provider number submitted. If it is then verify the provider's information with the enumerator; be sure all of the information entered is correct and complete, including tax ID numbers, addresses, phone numbers, etc. (Note: It takes from 5 to 7 days for our system to receive the updated information from the enumerator if changes are made.) If this information is correct then contact the provider enrollment department at (877) 567-7271.
210 INVALID FIRST NAME/INIT FOR HIC 12,802 claims
The last name submitted for the beneficiary does not match the last name we have on record for the HIC number on the claim. The beneficiary's last name must include apostrophes, spaces, hyphens, etc., if they appear in the beneficiary's last name on his or her Medicare card.
421 DIAG CODE (XXXXX) INVALID FOR DATE SVC 9,298 claims
The invalid diagnosis code will appear inside the parenthesis. Be sure that you are using the latest ICD-9 diagnosis codes, and that the code you are using is the most specific one. Also be sure that you are not using a date of service that is before the effective date of the diagnosis code.
333 INVALID PROVIDER NUMBER IN LOOP XXXXXX 9,128 claims
The provider number in the indicated loop is not valid. The invalid provider number used will appear in the text for the edit.

Insurance Verification

Does your practice verify benefits prior to seeing the patients? If not, why????? I have seen practices that see a patient that they have not seen in over a year, bill their previous insurance and guess, what it is no longer in effect. They then have to either track down the patient for their correct insurance or bill the patient (which most times results in no payment).

With all the cut backs that are affecting physicians we need to get the billing information correct upfront so the cash flow goes uninterrupted. So the first step is to make sure you have the correct billing information upfront. Verification of Benefits is a service we do provide.


Karen