PCCM Claims Reprocessing

November 8, 2011

PCCM claims were denied incorrectly for

  • 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).

A correction has been made, and reprocessing will start mid-November. In the first week, a portion of the claims will be re-processed and monitored. We anticipate that the remaining claims affected will be re-processed by the end of November.