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Last Modified: 1/6/2012
Location: FL, PR, USVI
Business: Part A
38035
This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider. One of the following conditions exists:
• The history claim user action code is equal to A-D, F-P or 'C', 'D', 'E', 'F', 'G', 'H', or 'R', and the reconsideration user action code is equal to 'R', and the incoming claim user action code is equal to 'C', 'D', 'E', 'F', 'G', 'H', or 'R', and the reconsideration user action code is equal to 'R'. --Or--
• The history claim user action code is blank and the reject code is not 5xxxx and the incoming claim user action code is 'C', 'D', 'E', 'F', 'G', 'H', or 'R', and the reconsideration user action code is equal to 'R'. --Or--
• The history and incoming claim user action code equals 'C', 'D', 'E', 'F', 'G', 'H', or 'R', and the reconsideration user action code is equal to 'R'.
• Statement from and thru dates are the same on both claims
• Provider numbers are the same
• At least one revenue code matches; or
• If the history or incoming claim has one of the following:
• HCPCS (healthcare common procedure coding system) modifiers - LT, RT, E1-E4, FA, F1-F9, TA or T1-T9; for the same HCPCS, and same date of service, ***and***
• The incoming or history claim has a blank HCPCS modifier, ***or***
• HCPCS modifier is not equal to the following - LT, RT, E1-E4, FA, F1-F9, TA or T1-T9
• At least one HCPCS code is the same on both claims (for 73x and 77x FQHC claims, blank HCPCS code is a match)
• If HCPCS/modifier (LT, RT, E1-E4, FA, F1-F9, TA or T1-T9) are equal on both the incoming and history claim, the 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 date of service is the same on both claims. For 71x, 73x, and 77x type of bill (TOB's), at least one diagnosis code must be the same.
Resources/tips to avoid or correct this reject code
Verify the status of your claims before refiling. There are several ways to verify this information:
• You can use the beneficiary health insurance claim (HIC) number to obtain a history of the claims you have submitted and the status/location of the claims using the direct data entry (DDE) 
claims inquiry function.
claims inquiry function.• Review the weekly 201 report available via DDE.
• Review the remittance advice.
There may be times you submit your claims through your software and use the electronic data interchange (EDI) gateway . Once you submit your claims electronically, the EDI gateway will send you a confirmation on the batch of claims received. Please wait on a confirmation prior to resubmitting the batch of claims. If you make one change to one claim in the batch and resend, the EDI gateway will allow all of the claims to go to the fiscal intermediary standard system (FISS), resulting in duplicate claims.
. Once you submit your claims electronically, the EDI gateway will send you a confirmation on the batch of claims received. Please wait on a confirmation prior to resubmitting the batch of claims. If you make one change to one claim in the batch and resend, the EDI gateway will allow all of the claims to go to the fiscal intermediary standard system (FISS), resulting in duplicate claims.Note: Duplicate claims are caused by resubmission of claims after payment 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. Errors that have been brought to a facility’s attention must be corrected.
Verify the HCPCS codes and modifiers on the claim. If necessary, correct as an adjustment to the originally submitted claim and resubmit.
Please use your browser's back button to return to the referring page.Source: FCSO Education Action Team
