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Last Modified: 3/8/2011
Location: FL, PR, USVI
Business: Part A
38037
This outpatient claim is a duplicate to a previously submitted outpatient claim. One of the following conditions exists on both claims:
• The statement ‘from’ date must match
• The incoming ‘from’ date is within the history claim ‘from and thru’ dates
• Provider numbers must match and one of the following conditions exists on both claims:
• Match on at least one of the revenue codes
• At least one HCPC (healthcare procedure coding) code is the same on both claims (for 73x and 77x FQHC claims, blank HCPC code is a match)
• If the history or incoming claim has one of the following HCPC modifiers -- LT, RT, E1-E4, FA, F1-F9, TA or T1-T9 for the same HCPC, and same date of service; and
• The incoming or history claim has a blank HCPC modifier; or
• HCPC modifier is not equal to the following -- LT, RT, E1-E4, FA, F1-F9, TA or T1-T9
• At least one diagnosis code must match
• Non-pay indicator not equal to 'R' and tape-to-tape flag is not equal to an 'X', 'Y', or 'Z'
• If HCPC/modifier (LT, RT, E1-E4, FA, F1-F9, TA or T1-T9) are equal on both incoming and history claim reason code will assign.
• In addition, effective for claims with a service date of 10/01/95 or later, at least one revenue code line item is the same on both claims
• This reason code is overrideable on page 09 of the UB92 screen for 73X and 77X type of bills (TOBs) only
• This reason code will not be assigned If the revenue/lab HCPC line contains a HCPC modifier equal to 'QR' or '91'
• For ambulance claims, this reason code will be bypassed if one claim has value code 32 and the other claim does not
• This reason code will assign when modifiers billed on the line are not equal (excluding special logic for modifiers listed above) and editing is performed at the HCPC level.
Resources/tips to avoid or correct this return to provider claim
Duplicate claims are caused by resubmission of claims after determination has been made on an initial claim. This could potentially result in duplicate payments. Billing that appears to be a deliberate application for duplicate payment of services or supplies may be considered fraud under the provisions of the Medicare program. If a facility is notified of an error and fails to correct it, an investigation may be opened.
There may be times you submit your claims through your software and use the electronic data interchange (EDI) Gateway. Once you submit claims electronically, the EDI Gateway will send you a confirmation on the batch of claims received. Please wait for confirmation receipt prior to resubmitting a batch of claims. If you make one change to one claim in the batch and resend, the EDI Gateway will allow all claims in the batch to go to the Fiscal Intermediary Shared System (FISS), resulting in duplicate claims.
Verify the status of your claims before refiling. There are several ways to verify this information.
• Direct data entry (DDE) 
claims inquiry: You can pull the beneficiary health insurance claim (HIC) number to see a history of the claims you have submitted and the status/location of the claims.
claims inquiry: You can pull the beneficiary health insurance claim (HIC) number to see a history of the claims you have submitted and the status/location of the claims. 
.• There are three breakdowns available:
• Claim status
• Return to provider
• Pending claims
• Review your remittance advice notice.
Please use your browser's back button to return to the referring page.Source: FCSO Education Action Team
