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From The Desk Of Ronda: CGS Medicare Suppliers: Update To The Claims Payment Alert For Incorrect MUE Processing

Both Jurisdictions B and C CGS Medicare issued an update on October 15th related to the MUE claims processing alert. Read their article below for details:

Jurisdiction B & C News from CGS

MUE Claim Alert Issue - Claims in Process September 22-26 

ANSI Reason Code: CO-151 ANSI Remark Code: MA01 HCPCS Codes Impacted: Multiple

Some claims may have processed against Medically Unlikely Edit (MUE) values incorrectly. The MUE files were incorrect in our system on 9/23/20–9/24/20, affecting claims that were in process on those dates (and continued to affect claims that began processing on those dates, even if the claim completion date was after the file was corrected). This resulted in two issues.  

Initial claims were processed against the MUE values incorrectly. This resulted in some initial claim lines allowing zero amounts and amounts should have paid on the claim lines.

CGS Action: CGS began adjusting the erroneously denied claim lines on 10/12/2020.

Additionally, claim adjustments (including reopening requests, appeal requests, CARES Act adjustments, or any other reasons that a claim would normally be adjusted) that were initiated or in process on 9/23/20 or 9/24/20 have also been impacted. In the case of many of these adjustments, because the initial claim had been paid, the now denied adjustment has automatically created an overpayment situation. You may incorrectly receive overpayment demand letters or immediate offsets regarding these claims. 

CGS Action 1: Two phases of adjustments will be necessary to issue correct claim decisions. First, CGS started adjusting claims and suppressing remittance advices on 10/13/2020. The first phase of adjustments will be to return the impacted claims to the appearance of the original claims but not generate remittance advices. The remittances are being suppressed in the first phase because the remittances and claim decisions will not be accurate. The second phase of adjustments will produce the correct remittances and claim decisions. 

CGS Action 2: Upon completion of the first phase adjustments, second phase adjustments will be completed on the claims to issue correct decisions and remittance advices.  

CGS Action 3: Not all CO-151 denials were processed incorrectly. We recognize it may be difficult to differentiate erroneous denials from valid CO-151 denials and that this may have impacts on timely filing of appeals. For those claims with valid CO-151 denials, CGS will issue new demand letters. The date on the newly issued demand letters will be the date used to determine timely filing of appeals.

CGS Action 4: Suppliers who have overpayments immediately offset and were immediately offset in error will be issued refunds if no other outstanding debts exist.

Supplier Required Action

Currently, suppliers do not need to take any action regarding the affected claims, adjustments, or overpayments.

For any further questions or issues reach out to Ronda Buhrmester at [email protected] or 217-493-5440.