Home Health Billing - Medicare Claim Status Information

Original source:  Palmetto GBA

Palmetto GBA has made Medicare claim status' inquiries easier to understand for your home health or hospice agency.  The claims go thru several processes prior to completed.  The process determines the claim status or provider action required.  It is encouraged to moniter the status of claims for possible errors or payment.

All claims submitted on the UB-04 claim form are processed in the Fiscal Intermediary Shared System (FISS). You may view the status and location (S/LOC) of the claims using the Online Provider Services (OPS) or Direct Data Entry (DDE) systems. Palmetto encourages monitoring the status and location of claims.

The six statuses in the FISS system include:

'S' Status (Suspended)
The claim is still in process and no provider intervention can be made.

• All incoming claims first go to the 'S' status
• Claims cycling in the Common Working File (CWF)
• Claims chosen for medical review

When a claim is in 'S' status, providers should wait for the claim to move to a completed status. Providers should not send another claim, and should monitor how long a claim is in this status. If a claim is in the same 'S' status and location for a period of longer than 30 days, providers may call the designated Provider Contact Center (PCC) to request that the claim be released and processed.

'P' Status (Paid/Processed)
The claim is completely processed and is either fully or partially paid.

'D' Status (Denied)
The claim is completely processed and denied by Medical Review.

• Providers can not adjust or cancel the claim
• The provider can submit an appeal/redetermination

'R' Status (Rejected)
The claim is completely processed and was rejected.

• Look at the reason code on the rejected claim and resubmit a new claim with corrections noted from the reason code narrative, if applicable
• Adjust the claim if it posted to the CWF and make the necessary corrections. Providers can determine if the claim was posted to the CWF by viewing the TPE-TO-TPE field in the system. If this field contains an 'X', the finalized claim was not posted to CWF.

'T' Status (Return to Provider)
The claim has been returned to the provider (RTPd) for correction.

• Review the reason code on the claim, make the necessary corrections and resubmit the claim
• Do not submit a new claim

'I' Status (Inactive)
The Medicare Administrative Contractor (MAC) has either inactivated or specially processed your claim.

• RTPs more than 60 days old and suppressed claims are moved to an 'I B9997' status for three years then purged
• A new claim may be submitted

Some of the most common status and locations

P B9996 Payment Floor

P B9997 Paid/Processed Claim

P B7501 Post-Pay Review

P B7505 Post-Pay Review

R B9997 Claims Processing Rejection

• Provider must either resubmit the claim or adjust it. See the job aid titled 'Determining Whether to Resubmit, Adjust or Appeal a Medicare Claim'.

DB9997 Medical Review Denial

T B9900 Daily Return to Provider (RTP) Claim

The claim is not yet accessible for the provider to correct.

T B9997 RTP Claim

• The claim may be accessed and corrected through the Claim and Attachments Corrections Menu (Main Menu Option 03) in DDE.

 

Understanding exactly where claims are located in the system is the key to determining what action, if any, can be taken to submit claims on the UB-04 claim form for corrections.

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