Allowing electronic submission of medically denied cancel claims, reason code 30940

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Home ► Billing news ► Allowing electronic submission of medically denied cancel claims, reason code 30940

Last Modified: 5/18/2024 Location: FL, PR, USVI Business: Part A

Reason code 30940

Reason code narrative

• A provider is not permitted to adjust a partially or fully medically denied claim.

• This reason code will edit when medically denied lines move into a covered status or medically denied lines are altered.

Most common problem:

Occurs when attempting to adjust a claim with a medically denied line.

Resolution

• Review the appropriate policy to determine the specific reason the service was not paid. Verify the diagnosis codes presented with the initial claim submission against the eligible diagnosis codes according to the applicable policy to determine if the denial is appropriate.

• If upon review you determine a diagnosis code needs to be changed or added, submit a claims correction via FISS DDE or you can submit a request to reopen the claim via First Coast, facsimile, esMD or mail.

• When adjusting claims with medically denied line items, do not move the charges to covered or remove the denial from the line to prevent this error from occurring.

• Remember, do not alter the denied line in any way.

• If the line(s) is found to be altered (even accidentally altered):

• If using DDE (Direct Data Entry) for claim submission, the RTP claim will need to be suppressed and resubmitted

• If the claim is submitted electronically and the provider has access to DDE a new adjustment can be submitted through FISS (DDE)

• If the provider only has access to electronic submission and no access to DDE cancel the original claim and rebill

§ Claims can only be referred to processing in the following scenarios:

• If the adjustments are MSP (Medicare Secondary Claims)

• If the original claim does not have any medical denials

• First Coast will allow electronic submissions to cancel claims with denied items and/or services. To ensure your claim is adjudicated appropriately, please be sure there are detailed remarks indicating the reason why the claim cancellation is necessary.

• For example, if you are submitting a claim cancellation due to an outpatient claim (013X type of bill) overlapping with an inpatient claim (011X type of bill) during the three-day payment window, add the remarks “Overlapping an inpatient claim” so the claim can be processed without manual intervention. All other remarks may cause the claim to suspend for claims processing manual intervention.

• Please keep in mind that there are certain scenarios in which hardcopy claim submissions (including adjustments and cancels) may be necessary. These include but are not limited to claim cancelation requests where Medicare is listed as the secondary or tertiary insurer.

• Providers can also appeal the denied claim/line items within 120 days of the claim denial by completing the Medicare Part A Redetermination and Clerical Error Reopening Form.

• If you disagree with the medical denial and have records to support the services, submit a redetermination request following the established protocol.

• If you are trying to add ICD-10-CM diagnosis codes, change CPT or HCPCS codes or move denied charges from non-covered to covered, submit a formal request for redetermination following the established protocol.

• If you are attempting to have the denied charges reversed, please submit a formal request for redetermination following the established protocol.

Reference:

§ Medicare Part A Redetermination and Clerical Error Reopening Request Form

Source: Provider Outreach and Education

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