Claims Rejections - Beneficiary Can’t be Identified
Providers submitting claims to HGSA as well as other carriers across the country are experiencing claims rejections because the beneficiary cannot be located on the eligibility records housed by the Common Working File (CWF). This file is maintained by the Centers of Medicare and Medicaid Services. An increase in the number of rejections began in October of 2004 which coincided with new and more stringent editing against the CWF database.
The reasons for the claim rejects involving a match of the beneficiary's name with the CWF information fall into three main categories described below. Please use this information to assess the appropriate remedy. Of course, our provider customer service representatives are available to assist as well.
I. Provider Reporting Errors
It is extremely important that providers and/or their billers report the beneficiary name exactly as it is shown on their Medicare card when submitting claims. This is the most common reason for these rejections.
For example, if the beneficiary's name on their Medicare card is "N. John Doe", with an "N" being the first name, "John" as the middle name and "Doe" as the last name, the provider must report it in that manner. In this example, we are finding that since the beneficiary routinely goes by his middle name, providers are reporting "John" as the first name, which is incorrect, and will cause a claim to reject.
II. Special Characters in Beneficiary's Name
The presence of a special character in the beneficiary's name such as an apostrophe or hyphen has resulted in rejections due to two different reasons.
A. CWF File Errors
CWF discovered a problem with the master eligibility records for a very small number of beneficiaries. The presence of a special character in the beneficiary's name on the eligibility file caused the eligibility records to be incorrectly established at CWF. In effect, the name, or initials within the name were blank and could not be matched by the name submitted on the claim record. These rejects would have occurred for paper as well as all EDI claims. CWF corrected this problem on March 3, 2005. Claims for beneficiaries with special characters in their name may be submitted either via paper or electronically depending on your billing software. (See II.B).
B. EDI Billing Software Limitations
Please contact your individual vendor to determine if your software supports the use of special characters.
The MCE software currently cannot support the use of special characters, and should not be used when the beneficiary's name contains a special character. If you use MCE software, then paper claims should be submitted when you encounter this situation.
III. Beneficiaries with Name Suffix (Electronic Claims Only)
Some beneficiary eligibility records at the CWF contain a name suffix such as "Jr." or "III" and are validated as part of the beneficiary name editing. This is causing rejections of some EDI claims. Paper claims are not affected.
It has been determined that the Medicare claims processing systems are not properly transferring the suffix information to CWF although it is correctly reported on EDI claims. This is causing the CWF to reject claims in the event that a beneficiary has a last name shorter than 6 characters on the CWF record (e.g. "Doe, Jr."). Claims for beneficiaries with last names with six or more characters are not affected by this condition (e.g. "Johnson, III")
Unfortunately we do not yet know when the Medicare claims processing system will be corrected to pass the suffix from EDI claims. You will be notified when the fix is scheduled. In the meanwhile, you should submit paper claims when you encounter this situation.