Last Modified: 2/5/2010
Location: FL, PR, USVI
Business: Part A
This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:
• HIC number
• Type of bill (all three positions of any TOB)
• Provider number
• Statement from date of service
• Statement through date of service
• Total charges (0001 revenue line)
• Revenue code
• HCPCS and modifiers (if required by revenue code file)
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For ambulance claims, this reason code will be bypassed if one claim has value code 32 and the other claim does not.
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For outpatient claims, this reason code is bypassed if either the history or incoming claim contained condition code G0.
Tips
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, and failure to do so will provide reasons to open an investigation.
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 the claims 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.
• Contact the interactive voice response (IVR) unit.
• There are three breakdowns available:
• Claim Status
• Return to Provider
• Pending Claims
• Review the weekly 201 report, which you can see through DDE. If you are not a DDE user, you will receive this report through the mail.
• Review the remittance advice.
Definitions:
Value code 32: multiple patient ambulance transport -- if more than one patient is transported in a single ambulance trip, report the total number of patients transported.
Condition code G0: distinct medical visit -- report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits.
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Source: FCSO Education Action Team
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