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Last Modified: 11/4/2011
Location: FL, PR, USVI
Business: Part A
Steps to avoiding reject reason code U5233 FAQ
Q: We are receiving reject reason code U5233 indicating the admission date falls within a risk Group Health Organization (GHO) paid period. What steps should we take to determine if a beneficiary is in a GHO?
A: Always remember to check beneficiary eligibility prior to submitting the claims to your Medicare Administrative Contractor (MAC). There are two ways to obtain this information:
1. Direct data entry (DDE) 
users can access the eligibility information by using the ELGA (eligibility A) screen. Hospice information will show on page 2.
users can access the eligibility information by using the ELGA (eligibility A) screen. Hospice information will show on page 2.2. Contact the Part A Interactive voice response (IVR) system .
.To bill for indirect medical education (IME), use the following guidelines:
• Your facility must be an approved facility in order to bill IME
• Type of bill = 11x
• Condition code 04 and 69 (see below for definitions)
• Medicare fee for service is the primary payer
• There is no Medicare secondary payer (MSP)
• Beneficiary's Medicare health insurance claim (HIC) number
• Revenue code 0024 containing CMG (case-mix groups) A9999 and include the discharge date in the service date field
• All other required claim elements (National provider identifier (NPI), charges, etc.)
Definitions:
Reject reason code U5233
For prospective payment system (PPS) claims, and claims with provider numbers beginning with '210', the admission date falls within a risk GHO paid period, but no GHO paid code or condition code '69', is indicated on the claim.
-or-
For non-PPS claims, and skilled nursing facility (SNF) claims, the statement dates fall within, or overlap, a risk GHO period, but no GHO paid code or condition code '69' is indicated on the claim.
Condition code 04 = Information only bill
• Code indicates bill is submitted for informational purposes only. Examples include a bill submitted as a utilization report or a bill submitted for a beneficiary who is enrolled in a risk-based managed care plan, and the hospital expects to receive payment from the plan.
Condition code 69 = IME/DGME/N&A payment only
• Code indicates a request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
Revenue code 0024 = Health insurance prospective payment system (HIPPS) inpatient rehabilitation facility (IRF) prospective payment system (PPS)
Source: CMS IOM Pub. 100-04, Chapter 25-Completing and Processing the Form CMS-1450 Data Set 
;
CMS IOM Pub 100-04, Chapter 2, Section 30.12; Chapter 3 , Section 20.8
;CMS IOM Pub 100-04, Chapter 2
, Section 30.12; Chapter 3 , Section 20.8
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