Physician - Most Common Denial Reasons

See below for most common denial reasons - physician.

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 timely from your remittance advice to avoid rebilling previously paid claims.

Error 4013 - Procedure Code Is Not Covered For Date of Service

Error: The service code entered on the claim is not covered on the date of service entered on the claim.

Resolution: Refer to Subchapter 6 of the Physician Manual for a listing of noncovered codes.

Error 0850 - Billing Deadline Exceeded - Detail

Error: MassHealth allows 90 days from the date of service 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 Physician Manual, when applicable.

Error 3121 - Invalid Referral Number

Error: The service authorization number entered on the claim does not match the service authorization number on file.

Resolution: Use the eligibility verification system (EVS) to verify the name and telephone number of the member's PCC and then contact the PCC to obtain the correct service authorization number. It is important to verify this information for each date of service as the member's PCC may change.

Note: If REVS indicates that the member is enrolled to a group practice, the first two digits of the referral number will typically be "97."

Error 0537 - Managed Care Referral Number Required

Error: The member is enrolled in the managed care program, and the services provided require a service authorization number from the member's Primary Care Clinician (PCC); however, a service authorization 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 service authorization number to enter on the claim.


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