Community Health Center - Most Common Denial Reasons

See below for the most common denial reasons - community health center.

Error 0542 - Member Ineligible Serv Date

Error: The member is not eligible for MassHealth on the date of service entered on the claim.

Resolution: To avoid this error, always verify member eligibility using EVS before to or on the date of service.

Error 0850 - Billing Deadline Exceeded - Detail

Error: MassHealth allows 90 days from the date of service or dates of explanation of benefits (EOB) to submit the initial claim to MassHealth. Claims submitted after 90 days will deny for this error.

Resolution: Providers should follow the procedures to obtain a 90-day waiver as outlined in Subchapter 5 of the Community Health Center Manual, when applicable.

Error 3120 -Referral Required On Claim

Error: The member is enrolled in the managed care program, and the services provided require a referral from the member's PCC but a PCC number was not entered on the claim.

Resolution: Use EVS to verify the name and telephone number of the member's PCC and then contact the PCC to obtain the referral number to enter on the claim.

Error 4021 - Procedure Code Not Covered Under Benefit Plan

Error: The service code entered on the claim is not covered for members enrolled in this coverage type. The member is enrolled in MassHealth Limited.

Resolution: Based on eligibility requirements, MassHealth members receive benefits according to specific coverage types. EVS provides the member's coverage type as part of the eligibility verification transaction. Refer to the specific MassHealth regulation at 130 CMR 450.105 for a list of covered services by coverage type and for other information and requirements about each coverage type.

Error 5044 - Exact Duplicate - Physician Claim

Error: The claim submitted is a duplicate of a claim previously paid for the same member, pay-to provider number, date of service, and service code. Some software systems will automatically generate "tracers" for claims that have not been posted.

Resolution: To avoid this error, post claims from your remittance advice in a timely manner to avoid rebilling previously paid claims.


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