When you submit a claim to us through electronic data interchange (EDI) and there’s a problem with the information submitted, we’ll send an immediate denial that will be noted in your electronic 277CA and submitter reports. This will allow you to quickly correct any errors and submit a new claim.
Denials related to eligibility
Critical member information fields, such as the patient’s first and last name, date of birth, and gender, must always be an exact match with what we have on file. If the member information on your claim doesn’t match what we have in our system, you’ll receive a message in your electronic 277CA and submitter reports outlining the issue.
Other immediate denials
In addition to eligibility mismatch denials, we will also start denying claims for two other types of errors:
- Medicare Advantage claims submitted with claim frequency code 5
- Claims submitted beyond the acceptable timely filing period
New submitter report codes
We’ve added several new codes to your electronic 277CA and submitter reports to help you better understand why a claim was denied.
| Code | Message |
|---|---|
| N70007 | The patient’s first name, last name, and date of birth do not match any member listed on this policy. |
| N70008 | The patient’s last name does not match any member listed on this policy. |
| N70009 | The date of birth and gender on the claim do not match the submitted patient name but are a match to a different member on the policy. |
| N70011 | This claim, for a Medicare Advantage member, was submitted with claim frequency code 5 (late charge request). The Centers for Medicare & Medicaid (CMS) does not allow claim frequency code 5 for Medicare Advantage members. |
| N70012 | This claim was not accepted for processing as it was submitted beyond the filing limit. The filing limit for replacement or late charges is one year from the receipt of the originally submitted claim. |
What should you do?
- For transactions denied due to mismatched eligibility:
- Submit an eligibility (270 inquiry) to obtain the correct patient information.
- Update the claim.
- Resubmit OR submit a replacement claim.
- For Medicare Advantage late charge claims, use frequency code 7 instead of 5. Additional information can be found in the CMS Claims Processing Manual and the Replacement Claim Request (frequency code 7) Guide.
- For timely filing issues, review Billing Guidelines in the provider Blue Book manual. Log in and go to Office Resources>Policies & Guidelines>Provider Manuals.
Questions?
If you have questions, please contact Provider Service at 1-800-882-2060.
Resources
- Correctly submitted claims will lead to timely payment
- Replacement Claim Request (frequency code 7) Guide
- CMS Claims Processing Manual
- Blue Book Billing Guidelines
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