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Claim Payment Alerts
Please reference this page for information about confirmed, system-related issues before you reach out to Customer Service. Click on the description to view details and check back often for updates that we post when they become available.
Closed issues remain on the active log for approximately 60 days before they move to the resolved issues archive list at the bottom of the page.
If you still have questions, please contact Customer Service or use one of our self-service tools.
Date Reported |
Description |
07.10.2025 |
CGS recently detected a significant number of incorrectly billed hospice claims. Claims have been submitted for continuous care using the admission date as the “From” date of service on the claim, instead of the beneficiary’s start of care date. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Hospice providers |
N/A |
TOB 8X3 or 8X4; admission date = "From" date of service |
|
MAC Action |
|
Provider Action |
Please review the "Attention: Hospice Billing Reminders & a New Claim Edit" article. |
Proposed Resolution |
|
|
05.01.2025 |
Reason Code U6802: Medicare Secondary Payer (MSP) claims may reject in error. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health & Hospice providers |
U6802 |
MSP claims |
|
MAC Action |
CGS will suspend claims until a system correction is installed. |
Provider Action |
No provider action. |
Proposed Resolution |
A system correction is in progress. |
|
03.11.2025 |
Reason Code U537I: Some home health claims for more than 36 periods of continuous care with the same home health agency (HHA) returned to provider (RTP'd) in error. See the Proposed Resolution section below for details. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Home Health |
U537I |
Claims for periods of care 37 and after |
06.16.2025 |
MAC Action |
|
Provider Action |
06.23.2025 – A CWF fix was deployed on 06.16.2025. You may F9 or resubmit impacted claims.
06.04.2025 – A CWF fix is scheduled on 06.16.2025. If you identify claims that RTP'd in error, please hold for resubmission. We'll update these instructions once the fix is tested and deployed.
05.14.2025 – This issue impacts claims with the following criteria:
- The claim admission date is on or after January 1, 2022.
- The beneficiary's eligibility record indicates more than 36 periods of continuous care with the same HHA.
- A valid reason for the edit (listed below) doesn't apply.
NOTE: Reason Code U5371 is valid, and you must take the appropriate action to resolve the edit if:
- There's no admission for the beneficiary and HHA on file.
- The NOA RTP'd or rejected.
- The HHA canceled and failed to resubmit the NOA.
- The NOA and claim admission dates don't match.
- A different HHA submitted an NOA with condition code 47.
- A claim with a prior date of service closed the admission.
|
Proposed Resolution |
06.16.2025 – A CWF fix was deployed.
06.04.2025 – A CWF fix is scheduled on 06.16.2025.
04.21.2025 – A system correction was installed.
03.11.2025 – In research: CWF only holds the 36 most recent periods of care for any beneficiary. When home health care is continuous for more than 36 periods of care, the oldest period that is purged may contain the NOA indicator that allows CWF to associate claims with an admission period on file. As a result, subsequent claims will RTP with reason code U5371, "The FROM and THROUGH dates on the HH claim fall outside of an HH admission period for the same provider." |
|
11.14.2024 |
Reason Codes 17729 & 17730: Hospice certifying physician edits applied to claims without occurrence code 27 in error. Please see the billing guidance for claim submission errors below. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Closed |
Hospice |
17729 & 17730 |
N/A |
11.18.2024 |
MAC Action |
|
Provider Action |
CR13531 implemented additional edits for hospice certifying physician Medicare enrollment on October 7 and November 18, 2024.
Please follow the billing instructions below.
Claim Physician Billing Information
- Prior to November 18, 2024: For admission claim submissions (occurrence code 27 certification date matches the admission and "from" dates), report the following in the attending field:
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- Enter a physician's name and NPI only. Don't enter a nurse practitioner (NP) or physician assistant (PA).
- On or after November 18, 2024: For admission claim submissions (occurrence code 27 certification date matches the admission and "from" dates), report the following in the attending field:
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- Enter an independent physician, hospice physician, NP or PA.
- For all non-admission claim submissions (admission and "from" dates don't match), regardless of submission date:
- Attending Physician Field
- Enter the name and NPI of the attending physician designated by the patient.
- If the patient didn't designate an attending physician, enter the hospice certifying/recertifying physician.
- The patient's designated attending physician could be an independent physician, hospice physician, NP or PA.
- Referring Provider Field
- Enter the name and NPI of the hospice's physician responsible for certifying patient's terminal illness.
- When no attending is designated, or the attending physician is also the certifying physician, only populate the attending physician field.
|
Proposed Resolution |
See Provider Action. |
|
08.01.2023 |
Reason Code 19963: Some home health claims returned to provider (RTP'd) in error because the corresponding NOA is offline. |
Status |
Provider Type Impacted |
Reason Codes |
Claim Coding Impact |
Date Resolved |
Open |
Home Health |
19963 |
NOA in Status/Location (S/LOC) O B9997 |
|
MAC Action |
3.27.2025 – Some HH claims with admission dates prior to August 23, 2023, and "Through" dates within approximately 18 to 24 months of the admission date continue to edit for 19963 in error.
This issue should not impact HH claims with admission dates after August 23, 2023, or claims with "Through" dates more than 24 months from the admission date.
02.22.2024 – CGS was not able to restore/process all affected NOAs/claims. See Provider Action update below.
10.06.2023 – CGS will restore the affected NOAs and process the associated claims within 45 calendar days.
08.23.2023 – A system update will not allow additional NOAs to move offline. |
Provider Action |
3.27.2025 – Continue to monitor RTP claims. If a claim RTP'd in error before January 6, 2025, F9 or resubmit for processing. If the edit is correct, see the instructions below.
01.06.2025 – Continue to monitor RTP claims and correct the NOA and/or claim when:
- There's no NOA on file for the admission.
- The NOA RTP'd or rejected.
- The HHA cancelled and never resubmitted the NOA.
- The claim admission date and NOA "From" date don't match.
- Another claim with earlier service date(s) closed the admission.
02.22.2024 – If you identify NOAs/claims that CGS was not able to restore/process per the MAC Action on 10.06.2023, please fax your list of claims to 615-660-5982.
Review claims that RTP with RC 19963. If a claim doesn't meet the criteria above, correct and resubmit it. |
Proposed Resolution |
See MAC Action and Provider Action.
Update: A system fix is scheduled for the January 2025 release.
01.06.2025 – CR13684 ensures home health claims submitted more than 24 months after the admission date don't RTP in error when the associated NOA is offline. |
|
Updated: 07.16.2025