Medicare Compliance & Reimbursement

C11 denials frequently befuddle physicians.

Medicare Remittance Notices are often confusing and fail to provide enough info about why a claim was denied.

Simple problems with filling out the CMS-1500 claim form can cause mystifying denials, say experts. A recent set of "frequently asked questions" from Part B carrier TrailBlazer's Internet site gives some examples of the problems physicians may have run into.

TrailBlazer says that as of June 30, it no longer allows providers to list 99999, "none," or "other" for Medigap insurer. Anyone who tries to answer the question about Medigap insurer with any of those items will receive a C11 denial, meaning "other payer primary ID invalid." But TrailBlazer says doctors can just leave that field blank unless the patient has Medigap insurance.

Another confusing issue: If a doctor put a dollar amount in Item 28 of the CMS-1500 claim form, the patient will receive the money instead of the provider. TrailBlazer explains that a doctor should only fill in item 28 if she collects money from the patient at the time of service. The amount in this item should refer to covered services that the patient has already paid for.

If Medicare has transferred a claim to another payer, the MRN can be difficult to decipher. TrailBlazer advises confused providers to look for Remark Codes or Reason Codes that explain the transfer, such as MA18, which means that claim information is being forwarded to the supplemental insurer.

It's often hard to figure out from MRNs what has happened to a claim, or why it has gone to a secondary insurer, says consultant Lisa Paoli with MedOffice Solutions in Des Plaines, IL. Her solution: She will call the carrier to get more information on the claim.

Tricky little e-claims: One provider asked TrailBlazer how to file Medicare Secondary Payer claims electronically and whether or not to send along the primary payer insurance statement with the claim. Physicians don't have to send the Primary Payer statement with the claim, but they do have to let Medicare know the amount the primary insurer paid, the amount the insurer allowed, and the amount they're "obligated to accept in full," TrailBlazer responds.

TrailBlazer also says physicians are always required to send MSP claims electronically. But that isn't always an option "due to the coding requirements and differences between carriers," such as different modifiers, says Ramey Becker with Pacific Practice Management in Lomita, CA. Becker usually changes codes and then submits them on paper along with a copy of the original insurer's explanation of benefits.

The biggest problem with MRNs and EOBs is that patients never understand how their coverage works and why they should owe any money, says Becker. Even patients who only have Medicare coverage feel they [...]