Tips to Prevent Reject Reason Code 34538

You receive this reason code when the beneficiary or the spouse was or is working for the date(s) of service and the employer’s insurance is primary to Medicare.

• Upon patient registration and prior to submitting the claim, ask the beneficiary to complete the Admission Questions to Ask Medicare Beneficiaries  located in the CMS MSP IOM, Pub. 100-05, Chapter 3, section 20.1.2. 

There are several ways to confirm beneficiary eligibility:

• Users can access eligibility information via Medicare Part A DDE User Guide Manual.
• Obtain the beneficiary’s eligibility via the SPOT.
  • If the information is invalid
    • The beneficiary or their representative must contact the MSP Contractor via Contacts at 1-855-798-2627, to have the record updated. Once the record is updated, refile the claim to Medicare for primary payment consideration.
  • If the information is valid
    • File the claim to the primary insurance listed on the beneficiary’s records and then to Medicare for secondary payment consideration.
• Note: Customer service representatives cannot assist you with eligibility information are are required by CMS to refer you to the portal.

Avoiding MSP Claim Rejects

Please review our article Avoiding MSP Claim Rejects for additional information.

You can refer to Part A Reason Code Lookup for a description associated with the Medicare Part A reason code. Enter a valid reason code into the box and click the submit button.

Reference

• CMS IOM Pub. 100-05 Medicare Secondary Payer Manual, Chapter 3