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Pennsylvania Claim Submission Errors - September 2007 Print

For Contract 00363 - Pennsylvania

Nbr.	Reason Code	Description	# of RTP Claims	Resolution
1.	32103	The National Provider Identifier (NPI) on the claim is not present on the crosswalk file.	5547	If your claim was submitted with only an NPI; please apply the appropriate legacy number to the claim. If the NPI is on the claim and you have verified with the NPPES registry that you are billing the correct NPI, verify on the NPPES website that your tax identification is correct and that your Medicare legacy number is valid.
2.	U5233	The admission date or statement from date falls within an HMO risk period.	3771	Ask the patient during the admission if they are enrolled in a Medicare Advantage plan, bill accordingly. It is also important to check HIQA to verify if the record indicates whether the patient is enrolled in a Medicare Advantage plan.
3.	31259	Value Codes A1, A2, A3, B1, B2, B3, C1, C2 and C3 are not allowed on the entry of direct data entry claim effective with dates on or after July 1, 2007.	1779	If your claim was submitted with one of these value codes, please remove it and resubmit.
4.	38117	The type of bill is equal to a SNF or claims for a non-PPS inpatient and the statement covers from date is greater than the admission date, there is a prior claim pending and the prior claim's thru date is 1 day less than this claim's from date.	1600	You must wait until the previous months claim has processed before sending the claim. The previous months claim should be in either a PB9996 or PB9997 status location.
5.	19301	If the operating physician is required, or if an operating UPIN is present, the physician's last name and first name must be present. If any name is present, the UPIN must be present or 'NPP' is an invalid UPIN. NPI implementation: When the claim receipt date is on or after the NPI implementation date in the system control file, the operating physician NPI must be present of if the operating physician NPI is present, the physician's last name and first name must be present.	1072	When submitting a claim that includes an operating physician, ensure the operating physician UPIN or NPI, last name and first name are present.
6.	38119	The type of bill is equal to a SNF or this claim is for a non-PPS inpatient. The statement covers from date is greater than the admission date, but there is no claim pending with a through date one day less than this claim's from date. Providers are required to bill SNF and non-PPS bills in sequence. This claim cannot be finalized until prior bill/s is received and processed.	712	Submit the previous month(s) in order of occurrence.
7.	31102	This claim is a request for conditional payment. The following requirements must be met for us to process the claim. Occurrence code 24 and the corresponding date the primary denied The appropriate value code (12, 13, 43, Etc.) This claim is not in accordance with Medicare's conditional payment regulations. Justification to process this claim conditionally has not been formatted correctly Justification remarks must be given exactly as it appears below: Justify: Proper claim filed with primary payer but the GHP denied the claims. Justify: Proper claim not filed with primary payer due to physical or mental incapacity of the person with Medicare. Justify: Proper claim filed with primary payer, but the no-fault or liability insurer denied the claim. Justify: Proper claim filed with primary payer, but the WC program denied the claim. Justify: Proper claim filed with primary payer, but the Federal Black Lung Program denied the claim. Justify: Primary payer not expected to pay within 120 days.	687	Add your justified remarks to page 4 of your claim; they must be typed exactly as written above, including spacing.
8.	31715	It has been determined that the units of service are in excess of the medically reasonable allowance for this service.	594	Verify the dosage and or quantity of the service provided. Next, check the CPT/HCPCS book to determine based on the description that you are billing the appropriate units. Correct your claim as needed.
9.	19202	One of the following error conditions has occurred: Attending physician UPIN characters four through sic are not numeric Attending physician UPIN characters one and three are alphabetic, but the surrogate UPIN is invalid. Valid \surrogate UPINS are: Inpatient: 'INT', 'RES", 'VAD", 'PHS', 'OTH', 'SLF' and 'RET' Outpatient: 'INT', 'RES', 'VAD', 'PHS', 'OTH', 'SLF', 'RET' 'NPP is an invalid UPIN	564	Prior to the submission of a claim, ensure the attending physician's UPIN is valid.
10.	32402	Invalid revenue code for the HCPC reported. Or, the HCPC is not valid for the date on which the services were provided.	541	Prior to submission of a claim, verify the HCPCS billed, the revenue codes billed, and the 'From' and 'Through' dates on the claim.

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