New Remittance Advice for Referred Duplicate Services

Effective April 01, 2005, CMS implemented a new Common Working File (CWF) edit to check for duplicate claims for referred clinical diagnostic laboratory services and purchased diagnostic services submitted by suppliers to more than one carrier. (Per Transmittal 124, Change Request 3551)

Claims submitted for referred clinical diagnostic/purchased diagnostic services will be considered duplicate when:

  • The claims contain different carrier numbers, and,
  • All of the data matches on the following claim fields:
    • Beneficiary Name
    • Beneficiary Health Insurance Claim Number (HICN)
    • Current Procedural Terminology (CPT) Code
    • Date of Service
    • CPT Code Modifier

The CWF duplicate claim edit will apply only to:

  • Claims containing a CPT code that is included on the clinical laboratory fee schedule

Effective for claims processed on or after July 1, 2005, CMS will implement a new Remittance Advice (RA) message for claim items denied due to the CWF duplicate claim edit for referred clinical diagnostic/purchased diagnostic service claims:

  • Carriers will use remark code (N347) on remittance advice notices generated for a referred clinical diagnostic/purchased diagnostic service claim line item denied as a duplicate of a previously paid service: “Your claim for a referred or purchased service cannot be paid because payment has already been made for this service to another provider by a payment contractor representing this payer.”

Published by XIFIN

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