Novice Know How
When monitoring coding and coverage for claims submitted by newly enrolled WPS Medicare providers, one top denial continues to be for duplicate claims. Duplicate claims account for approximately six percent of all claims filed to Medicare Part B and cost the Medicare program millions of dollars annually. Duplicate submissions cost providers money by increasing staff time and effort as well as practice expenses (i.e., a billing service charges per claim submission). Carriers spend additional time, effort and money when duplicate claims increase the number of claims and appeals
Although duplicate claim submissions will occur from time to time, Medicare expects the rate of occurrence to be less than one percent of all claims processed. Medicare works with providers to eliminate duplicate claims whenever possible. The following questions and answers offer tips for providers, both new and established, to avoid duplicate denials.
Q1: How can I identify claim submission dates to find a duplicate claim?
A1: Medicare claims are assigned Internal Control Numbers (ICNs) to identify how and when Medicare received the claim. The ICN appears on the Provider Remittance Notice (PRN).
In Wisconsin, Illinois, Michigan and Minnesota:
The first seven numbers indicate the region (whether the claim was an electronic or paper claim), the year the claim was submitted, and the date Medicare received the claim (Julian date).
A PRN with an ICN of 2205225056020 is read as follows:
- Positions 1-2 indicate the region. Electronic claims are assigned region codes 02, 09, or 10 for Illinois, 11, 18, or 19 for Michigan, 22, 28, or 29 for Wisconsin, and 32, 38, or 39 for Minnesota. The first two positions of the above ICN example are "22," so the claim was submitted electronically in Wisconsin.
- Positions 3-4 indicate the year the claim was submitted. In this example, the "05" means the claim was submitted in 2005.
- Positions 5-7 indicate the date the claim was received (by Julian date). The Julian date is defined as the "sequential day count of the days of a year, reckoned consecutively from the first day of January." This claim was received on day 225 of 2005, or August 13, 2005.
The last six positions represent internal batch and sequence numbers assigned to the claims submitted on that day. With this information, providers may refer back to the confirmation/acknowledgment and/or claim submission summaries to determine the source of the duplicate problem.
Q2: How long should I wait before I re-file my claims when I haven't heard from Medicare?
A2: Before re-filing a claim, allow sufficient time for the claim to reach Medicare, for Medicare to process the claim, and for the Provider Remittance Notice to reach you. If you do not submit claims electronically or receive your remittance notice electronically, you must allow time for mail processing and delivery. Claim processing time cannot be shorter than the "payment floor," which is 13 days for electronic claims, and 26 days for paper claims. This is the minimum amount of time that must elapse from the date Medicare receives the claim until the date Medicare issues a payment. Actual processing time can take longer. Also, before re-filing, always carefully review your PRN to reconcile your records and access the Interactive Voice Response (IVR) system for claim status, or contact the Provider Inquiry Line for the status of specific claims if you are unable to determine status from your PRNs or the IVR.
Do not automatically re-file claims to Medicare Part B without first obtaining the status of the original claim. If your software automatically re-files claims, please disable this software capability, or reset your system to wait a sufficient amount of time after the claims have reached the payment floor. It is not appropriate to use an automatic re-filing system as an alternative to bookkeeping.
You can avoid duplicate claims by tracking claims submitted and processed. When submitting a claim, send either a paper or electronic claim. Do not submit the same claim both ways. Please note that only certain providers are still allowed to submit paper claims due to the Health Insurance Portability and Accountability Act requirements.
If you receive a duplicate denial for a service that is not actually a duplicate service, you will need to request an appeal to remedy the situation.
Q3: What if I have software problems?
A3: If you determine that your computer system is inadvertently resubmitting claims without your knowledge, contact your electronic claim submission software support vendor immediately.
Q4: What are some other things I can do to help avoid duplicate denials?
A4: The following are some helpful suggestions:
- When resubmitting a claim to obtain payment for denied charges, submit only the denied charges.
- Use modifiers appropriately. For more information on modifiers please refer to our manual titled "Common Medicare Modifiers" located on the WPS Medicare Website.
