Primary Care Case Management (PCCM) Claims Denying Inappropriately

October 28, 2011

Due to the postponement of the referral number being entered on claims, we are experiencing a high volume of claims being denied inappropriately.

Claims affected by this issue will appear on the Remittance Advice (RA)with the following denial reason codes:

  • Edit 330 – Invalid Diagnosis Code for Benefit. The denial reason code on the Remittance Advice is M64(Missing/incomplete/invalid other diagnosis).

  • Edit 271 – Benefit Restriction Group Validation Failed. The denial reason code on the Remittance Advice is B5 (Coverage/program guidelines were not met or were exceeded).

  • Edit 152 – Payment is denied when performed/billed by this type of provider. The denial reason code on the Remittance Advice is N95 (this provider type/provider specialty may not bill this service).

To resolve this issue, we will update the member benefits so you may see a warning on your RA stating that the service you performed requires a referral. Most of these will be valid warnings and will be enforced once we turn on the referral editing; however, some of these will not be valid warns as the service may not require a referral. If you question the warning, please refer to your PCCM manual for clarification.

This issue is being addressed and affected claims will be adjusted on a future RA. The affected claims will be reprocessed. You do not need to resubmit these claims.