Advanced Revenue Cycle Analytics: An Overview

OGMM6Q0Managing denied medical claims has historically been very time consuming and often confusing for many practices. To help simplify the process, we are going to cover the standard Denial Reason Codes & Statements for Medicare Part A and Part B.

Let’s begin with what CMS had to say:

 

“CMS contractors medically review some claims (and prior authorizations) to ensure that payment is billed (or authorization requested) only for services that meet all Medicare rules. If the review results in a denied/non-affirmed decision, the review contractor provides a detailed denial/non-affirmed reason to the provider/supplier.

Historically, Medicare review contractors (Medicare Administrative Contractors, Recovery Audit Contractors and the Supplemental Medical Review Contractor) developed and maintained individual lists of denial reason codes and statements. If you deal with multiple CMS contractors, understanding the many denial codes and statements can be hard. In 2015 CMS began to standardize the reason codes and statements for certain services.

As a result, providers experience more continuity and claim denials are easier to understand.

A new set of Generic Reason codes and statements for Part A, Part B and DME have been added and approved for use across all Prior Authorization (PA), Claim reviews (including pre-pay and post-pay) and Pre-Claim reviews.  These generic statements encompass common statements currently in use that have been leveraged from existing statements.”

Download the Full Denial Code List for Medicare Part A & B

The following are the reason codes and statements provided by CMS for Medicare Part A & Part B.

MEDICARE PART A
Denial Reason Codes & Statements

 

Reason Code

DUPLICATES

GAA01This is a duplicate of a service already submitted. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120-120.3
GAA02This is a duplicate of a previously submitted claim. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120-120.3

 

Reason Code

INSUFFICIENT DOCUMENTATION

GAI01Provider did not submit all records requested. Refer to Internet-Only Manuals, Pub 100- 08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
GAI02Provider did not submit additional records requested. Refer to “Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
GAI03Incomplete/Insufficient information. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, 42 CFR 424.5(a)(6), Social Security Act 1833(e)
GAI044 The documentation submitted did not support the service(s) billed as being rendered. Refer to Internet-Only Manuals-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A
GAI05The documentation submitted did not include a signed physician order or documentation to support intent to order. Refer to Internet-Only Manuals, Pub 100-08, Chapter 3, Section 3.6.2.2 Social Security Act Section 1842(p)(4), Internet-Only Manuals, Pub 100- 08, Chapter 3, Section 3.3.2.4, 42 CFR 410, Internet-Only Manuals 100-02, Chapter 15, Section 80.6.1
GAI06The documentation submitted did not contain an order that was sufficiently specific to support the service. Refer to 42 CFR §410.32(a) (supports diagnostic tests), §410.32(d)(3) (diagnostic tests), Social Security Act 1862(a)(1)(A), Internet-Only Manuals, 100-02 MBPM Chapter 15, Section 50 (specific to drugs)
GAI07The documentation submitted did not support signature requirements were met. Refer to Internet-Only Manuals, Pub 100-08, Chapter 3, Section 3.3.2.4
GAI08The documentation submitted was illegible. Refer to Medicare Program Integrity Manual Chapter 3 Section 3.3.2.1
GAI09The documentation submitted was for the incorrect service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GAI10The documentation submitted was for the incorrect beneficiary. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GAI11The documentation submitted was for the incorrect dates of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GAI12The documentation submitted did not include signed documentation to support the medical necessity of the services provided. Refer to Medicare Program Integrity Manual (Pub.100-08) Chapter 3, Section 3.3.2.4, Social Security Act 1862(a)(1)(A)

 

Reason Code

MEDICAL NECESSITY

GAJ01The documentation submitted does not support medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manuals-Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3
GAJ02Service provided is not a covered Medicare benefit. Refer to Social Security Act 1862, 42 CFR 411.15
GAJ03The documentation submitted supports the service rendered was for provider/beneficiary comfort or convenience. Refer to 42 CFR 411.15 (j)
GAJ04The documentation submitted does not support the need for this many services or items within this period of time. Refer to Social Security Act 1862(a)(1)(A)
GAJ05The documentation submitted does not support the ordered protocol was followed. Refer to Social Security Act 1862 (a)(1)(A) and Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2, Medicare Claims Processing Manual Chapter 30 Section 40

 

Reason Code

BILLING

GAK01The documentation submitted supports an excluded service was billed. Refer to Social Security Act 1862.
GAK02This claim was recoded to reflect the level of services supported by the documentation submitted. Refer to “Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 Internet-Only Manuals 100-08, Medicare Program Integrity Manual Chapter 6, Sec 6.5.3 (DRG validation)
GAK03The documentation submitted supports this service is an integral part of another service received on the same day and cannot be billed separately. Refer to Medicare Claims Processing Manual Chapter 23- Section 20.9.2
GAK04The documentation submitted does not support the number of units billed. Refer to “Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 (coding determinations) and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23 (description of HCPCS); AMA CPT Professional coding guidelines PUB 100-4 Ch. 4 Section 20.4 (UOS), 42 CFR Section 414.40, AMA HCPCS Professional coding guidelines
GAK05The documentation submitted does not support the modifier used. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23, PUB 100-4 Ch. 4 Section 20.6 (UOM)
GAK06This service or procedure is considered investigational and, therefore, not covered by Medicare. Refer to Social Security Act 1862 (a) (1) (A), Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GAK07Service denied due to the beneficiary’s Medicare benefits having been exhausted. Refer to Internet-Only Manuals, Pub 100-02, MBPM Chapter 5 and Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5 A
GAK08The claim was changed to reflect the actual service provided. Refer to Internet-Only Manuals, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23
GAK09Documentation does not support the claim as billed. Refer to Internet-Only Manuals, 100- 08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 100-04 Medicare Claims Processing Manual, Chapter 23
GAK10Documentation supports the service provided was not covered and the beneficiary received a valid Advanced Beneficiary Notice (ABN) of Noncoverage, therefore the beneficiary is liable for charges incurred on this bill. Refer to Internet-Only Manuals 100- 4, Medicare Claims Processing Manual Chapter 30, 100-4 Medicare Claims Processing Manual, Chapter 30
GAK11Medicare agrees with the provider’s determination that the service billed is non-covered. Refer to Internet-Only Manuals 100-4 Medicare Claims Processing Manual, Chapter 30
GAK12Documentation supports the service provided was not covered, however, the Advanced Beneficiary Notice (ABN) of Noncoverage was invalid, therefore the provider is liable for charges incurred on this bill. Refer to Internet-Only Manuals 100-04, Medicare Claims Processing Manual Chapter 30, 50.6.1

 

Reason Codes

INCOMPLETE/INCORRECT CLAIM INFORMATION

GAL01Claim did not contain a valid NPI. Refer to Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70.8.8.6, Section 80.3.1
GAL02Documentation supports the provider was ineligible for payment at the time the service was rendered. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual Chapter 3 Section 3.6.2.5 B; 42 CFR § 424.5(a)(2)
GAL03Services should have been billed to another contractor. Refer to Medicare Claims Processing Manual Chapter 1 Section 10

 

Reason Codes

CERTIFICATION REQUIREMENTS

GAM01The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3

 

Reason Codes

ADMINISTRATIVE

GEX01The file is corrupt and/or cannot be read
GEX02The submission was sent to the incorrect review contractor
GEX03A virus was found
GEX04Other
GEX05The system used to retrieve the Subscriber/Insured details using the given MBI is temporarily unavailable.
GEX06The documentation submitted is incomplete
GEX07This submission is an unsolicited response
GEX08The documentation submitted cannot be matched to a case/claim
GEX09This is a duplicate of a previously submitted transaction
GEX10The date(s) of service on the cover sheet received is missing or invalid.
GEX11The NPI on the cover sheet received is missing or invalid
GEX12The state where services were provided is missing or invalid on the cover sheet received.
GEX13The Medicare ID on the cover sheet received is missing or invalid.
GEX14The billed amount on the cover sheet received is missing or invalid.
GEX15The contact phone number on the cover sheet received is missing or invalid.
GEX16The Beneficiary name on the cover sheet received is missing or invalid
GEX17The Claim number on the cover sheet received is missing or invalid
GEX18The ACN on the cover sheet received is missing or invalid

 

MEDICARE PART B
Denial Reason Codes & Statements

 

Reason Code

Duplicates

GBA01This is a duplicate service previously submitted by the same provider. Refer to IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1 section 120- 120.3
GBA02This is a duplicate service previously submitted by a different provider. Refer to IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1 section 120- 120.3

 

Reason Code

Insufficient Documentation

GBB01The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8
GBB02The documentation submitted was incomplete and/or insufficient. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, B/C
GBB03The documentation submitted does not support services were rendered as billed. Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A
GBB04The documentation submitted did not include a physician order. Refer to IOM, Pub 100-08, Chapter 3, Section 3.6.2.2
GBB05The documentation submitted was missing patient identifiers. Refer to Standards for Adequacy of Medical Records; Section 1833 (e), Title XVIII, of the Social Security Act.
GBB06The documentation submitted was for the incorrect date of service. Refer to Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GBB07The documentation submitted does not support the modifiers billed. Refer to Medicare Program Integrity Manual Chapter 3, IOM Pub 100-04, Medicare Claims Processing Manual Chapter 1
GBB08The ABN is invalid, incomplete or missing. Refer to Medicare Claims Processing Manual Chapter 30, Section 40.3.6
GBB09The documentation submitted was for the incorrect beneficiary. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8
GBB10The documentation submitted is not legible. Refer to Medicare Program Integrity Manual, Chapter 3 Section 3.3.2.1
GBB11The documentation submitted does not support the number of units billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23

 

Reason Code

Medical Necessity

GBC01The documentation submitted does not support medical necessity as listed in coverage requirement. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.2
GBC02The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2
GBC03The service billed is not a covered Medicare benefit or is an excluded service. Refer to 42 CFR 411.15. Medicare Benefit Policy Manual Chapter 16; CFR title 42, Chapter IV, subchapter B, part 411
GBC04The documentation provided does not support the medical necessity for this number of services or items within this timeframe. Refer to SSA 1862, IOM, 100- 08, MPIM Chapter 3, Section 3.6.2.2
GBC05The maximum benefit has been reached for this service. Refer to IOM, Pub 100- 02, Medicare Benefit Policy Manual Chapter 5 and IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5 A
GBC06The documentation indicates that the service was performed for routine/screening purposes but is not covered under Medicare’s Screening Benefit. Refer to Medicare Claims Processing Manual Chapter 18

 

Reason Code

Miscellaneous

GBD01Billing Error. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4; 100-04 Medicare Claims Processing Manual, Chapter 23.
GBD03Bundled or included in another code billed (NCCI). Refer to Medicare Claims Processing Manual Chapter 12, Section 20.3; National Correct Coding Initiative Coding Policy Manual for Medicare Services; Medicare Program Integrity Manual Chapter 4.2.1
GBD04The documentation does not support the service was performed as billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23
GBD05The documentation does not support the diagnosis code billed. Refer to Medicare Program Integrity Manual Chapter 4.2.1
GBD06Payment for this service is compensated in the global surgical period. Refer to Medicare Claims Processing Manual Chapter 12 Section 30.6.6
GBD07Payment is included in another service received on the same date (bundled). Refer to Medicare Claims Processing Manual Chapter 12, Section 30 & 40
GBD08This service or procedure is considered investigational and, therefore, not covered by Medicare. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2
GBD09The documentation submitted does not support the ordered service. Refer to IOMPub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5, A
GBD10The documentation does not support that a separately identifiable service was performed. Refer to IOM Medicare Claims Processing Manual Chapter 12, Section 30.6; Section 1833 (e), Title XVIII, of the Social Security Act
GBD11The appropriate primary code has not been billed or paid. Refer to IOM-Pub 100- 08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4
GBD12The documentation submitted indicates the service was performed for cosmetic purposes. Refer to Medicare Benefit Policy Manual Chapter 16, Section 120
GBD13The documentation submitted contains cloned or altered information. Refer to Pub 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5; Chapter 4.3
GBD14The provider indicated services were billed in error. Refer to Section 1833 (e), Title XVIII, of the Social Security Act
GBD15The documentation contains conflicting information. Refer to Medicare Program Integrity Manual Chapter 4.3
GBD16The service or device was not FDA approved. Refer to SSA 1862; Medicare Benefit Policy Manual Chapter 14
GBD17The service billed is statutorily excluded. Refer to Medicare Claims Processing Manual Chapter 30, Section 20.1.1, Social Security Act 1862 (a), 12 CFR 411.15, Medicare Benefit Policy Manual Chapter 16
GBD18The documentation submitted supports the performing and billing providers are different.

 

Reason Code

Downcoded/Recoded Based on Level of Service Provided

GBE01The documentation submitted does not support the medical necessity of the level of service billed. Refer to IOM, 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.4 and Section 3.6.2.5, Medicare Claims Processing Manual Chapter 23
GBE02The documentation submitted does not support the level of service billed. Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.4

 

Reason Code

Signature Denials

GBF01The documentation submitted did not include a valid signature and/or credentials. Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part 482.24
GBF02The documentation submitted did not include a valid signature and a response to attestation or signature log request was not received. Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4 and CFR Part 482.24
GBF03Stamped signatures are not accepted. Refer to IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4

 

Reason Code

Certification Requirements

GBG01The documentation submitted did not include the required certifications or recertifications. Refer to Medicare Benefit Policy Manual, Chapter 15, 220.1.3

 

Reason Code

Other

GBH01The claim did not include a valid NPI. Refer to IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 1, Section 80.3.1
GBH02The claim submitted did not contain required information.

 

Reason Code

Administrative (For Transmission via esMD)

GEX01The file is corrupt and/or cannot be read
GEX02The submission was sent to the incorrect review contractor
GEX03A virus was found
GEX04Other
GEX05The system used to retrieve the Subscriber/Insured details using the given MBI is temporarily unavailable
GEX06The documentation submitted is incomplete
GEX07This submission is an unsolicited response
GEX08The documentation submitted cannot be matched to a case/claim
GEX09This is a duplicate of a previously submitted transaction
GEX10The date(s) of service on the cover sheet received is missing or invalid.
GEX11The NPI on the cover sheet received is missing or invalid.
GEX12The state where services were provided is missing or invalid on the cover sheet received.
GEX13The Medicare ID on the cover sheet received is missing or invalid.
GEX14The billed amount on the cover sheet received is missing or invalid.
GEX15The contact phone number on the cover sheet received is missing or invalid.
GEX16The Beneficiary name on the cover sheet received is missing or invalid
GEX17The Claim number on the cover sheet received is missing or invalid
GEX18The ACN on the coversheet received is missing or invalid

 

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