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Mismatched clearinghouse submitter IDs, system failures and missing enrollment documents are top reasons claims are being rejected or processed slowly. CMS announced it lifted its claims hold, which was in place to allow MACs to update their systems to reflect the temporary conversion rate, on Jan. 17 and immediately started paying claims. However, many providers see this as no more than the saying, "the checks in the mail".

Some providers haven’t been paid since November 2011 as a result of such issues. And even though practices are reaching out to their MACs, many get “little to no information” except being told the blame lies with the clearinghouses or software vendor.

Reason's why claims are being rejected:

  • Delayed or missing claims status responses.  Responses that are coming back are taking 5 days instead of the normal 2 days.
  • MAC system failures. Some MACs are experiencing system failures and can’t accept 5010 claims quickly or at all due to the large volume.  CMS says backlogs have been cleared except for National Government Services (NGS), the MAC for Indiana, Connecticut and New York.
  • The address listed on your claim differs in any way from the enrollment form. For example, If your enrollment form said, "225 E Robinson" and you are now sending "225 East Robinson".  However, CMS says this is not an issue.
  • Provider no longer enrolled in Medicare.  Since Jan. 1, providers’ claims have been bouncing back because their enrollment with CMS is no longer valid. CMS is aware of the issue and is working on a fix.
  • Clearinghouse submitter ID isn’t linked to your national provider identifier (NPI). During the 5010 switch, provider NPIs became unmatched from their clearinghouses’ submitter ID, resulting in all claims being rejected. (This was not an issue for CMD customers.)

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