(Medicare Claims Processing Manual)

5. With Error Code 5057 -  The Host returns disposition code 50 with Trailer 08 and error code 5057 (Skeleton on HI Master File).  This indicates that the beneficiary has died.  There has been no claims activity for six months  since date of death, and the beneficiary information is located on the inactive file.  A/B MACs and DME MACs  research the HICN and confirm that the HICN submitted on the claim is correct.  If incorrect, resubmit the claim with the correct HICN.   If the orig inally submitted HICN was correct, the A/B MAC or DME MAC  recycles the claim every 15 working days to allow CMS time to retrieve the records.    After 45 working days have passed with no approval, adjustment, or reject (AAR) response, MACs contact their RO. 6. With Error Code 5058 -  The Host returns disposition code 50 with Trailer 08 and error code 5058 (Blocked).  The records have been blocked due to cross -reference activity.  There are two numbers for one beneficiary, both of which show claims activity.  The information is manually placed under one primary number in one record.  MACs recycle the claim every 15 working days to allow time for CMS processing.   After receiving a second code 58, they contact the RO. 7. With Error Code 5059 -  The Host returns this as disposition code 50 and Trailer 08 with error code 5059 (Frozen).  Miscellaneous clerical corrections are being made to these beneficiary records.   MACs recycle the claim every 15 working days.   After receiving a second code 59, the A/B MACs or DME MACs  contact the RO. 20.3.3.2 - Disposition Code 51 (True Not in File on CMS BatchSystem)   (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The Host gives this response with a 08 Trailer and error code 5052.  The CMS has performed an alpha search of its records and cannot locate the beneficiary's records.  Alpha search is the process of searching for the records based on the first six positions of the surname.  All beneficiaries with the same first six letters in their sur names are listed with their HICNs.  The system checks for possible matches, including the possibility that numbers were transposed.  This search is performed only if no match is found during the search by HICN.  This code can be given in two forms:  1.  With  Trailer 01  - Trailer 01 will contain a possible corrected HICN.  The A/B MAC or DME MAC  investigates the possible HICN and, if it believes the new HICN is for the same beneficiary, it resubmits the claim with the new HICN to the Host.  The CWF will respond with the appropriate disposition code and any associated trailers for processing the claim.  2.  Without Trailer 01 -  This response indicates that after performing the alpha search operation, no match is found against the HICN submitted and CMS records.  Since Medicare eligibility cannot be established, A/B MACs and DME MACs  shall return the claim to the provider as unprocessable and take the following actions:   A/B MACs (A, HHH ) shall return to provider (RTP) Part A claims.  A/B MACs (A, HHH)  shall not mail an MSN for these claims.   A/B MACs (B) and DME MACs  shall return as unprocessable Part B claims.  A/B MACs (B) and DME MACs  shall use Group Code CO and Claim Adjustment Reason (CARC) 140 (Patient/Insured health identification number and name do not match).  A/B MACs (B) and DME MACs  shall not mail an MSN for these claims.   For assigned and unassigned Part B claims submi tted by the beneficiary on the Form CMS -1490S or Form CMS -1500, A/B MACs (B) and DME MACs  shall manually return the claim in accordance with Pub.100- 04, chapter 1, section 80.3.2 A. "Special Considerations."  20.3.3.3 - Disposition Code 52 (Beneficiary Reco rd at another Host)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18)  When CMS receives a request for transfer, it searches its Master File to determine if the Beneficiary Record resides at another Host.   The CMS first searches th e record based on the HICN.  If a match is found, and the beneficiary has not already been assigned to a Host, CMS sends the records to the requesting Host. After the Host receives the record, it can process the claim from the MAC on its next cycle.   If a m atch is found that indicates the beneficiary has been assigned to another Host, CMS sends the requesting Host a code 52. The requesting Host then sends the claim information to the receiving Host that has the Beneficiary Record.   The requesting Host will gi ve the processing MAC a code 52 and Trailer 08 with a 5052 error code.   The MAC holds the claim and resends (recycles) it in five working days to see if there is a response waiting.   If the response is present on the first recycle of the claim, the MAC finis hes processing the claim according to the response.   If a response is not present, the MAC receives another disposition code 52 and the claim is sent to the proper Host for processing.   The MAC recycles the claim after another five working days, and continue s recycling the claim until it receives an approval, adjustment, or reject (AAR) response, or until 45 working days have passed.   After 45 working days have passed with no AAR response, the MAC reports the problem to the Host through locally established reporting procedures.  20.3.3.4 - Disposition Code 53 (Record in CMS Alpha Match)                  (Rev. 4047, Issued: 05- 11- 18, Effective: 08 -13-18, Implementation: 08- 13-18)  If CMS sends a claim to alpha search, it must send a disposition code 53 to the Host.  The Host puts a code 53 on its TNIF file.   The Satellite receives code 53 and Trailer 08 with a 5052 error code on the next recycle of the claim.   The Satellite must recycle the claim 15 working days after receiving this code.   If an AAR response is not received after the receipt of the third code 53 for the same claim, the Satellite must deny the claim using the following messages: MSN message 5.1:  "Our records show that you do not have Medicare entitlement under the number shown on this  notice. If you do not agree, please contact your local Social Security office."  Group Code CO, Claim Adjustment Reason Code (CARC) 16 (Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.  Do not use this code for claims attachment(s)/other documentation.  At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identific ation Segment (loop 2110 Service Payment Information REF), if present), and Remittance Advice Remark Code (RARC) N382 -  Missing/incomplete/invalid patient identifier . 20.3.3.5 - Disposition Code 54 (Matched to Cross -referenced HICN)  (Rev. 4009, Issued: 03- 23-18, Effective: 04 -23-18, Implementation: 04- 23-18) The Host provides the MAC with disposition code 54 and Trailer 08 with error code 5052 when it discovers a cross -reference number in its own files for the name or number the MAC submitted. Disposition C ode 54 applies only to A/B MAC (B) or DME MAC - submitted claims.  The possible number and the new full name is returned to the MAC on Trailers 1 and 10.   The A/B MAC or DME MAC investigates the information provided and corrects the information on the claim and resends it.   If the MAC continues to receive a code 54, it contacts the Host through locally established procedures.  20.3.3.6 - Disposition Code 55 (Personal Characteristic Mismatch)         (Rev.  4047, Issued: 05- 11-18, Effective: 08 -13-18, Implementati on: 08- 13-18) The Host provides the Satellite with this disposition code and Trailer 08 with error code 5052 when it discovers a mismatch of the Health Insurance Claim Number (HICN) with the beneficiarys personal characteristics such as name, sex or date of birth.  If CWF rejects a claim and sends back disposition code 55 with the 08 trailer containing Error Code 5052 when the beneficiarys personal characteristics do not match the HICN in accordance with the CWF matching criterion, contractors shall retur n the claim to the provider as unprocessable with the identifying beneficiary information from the submitted claim as follows: A/B MACs (A, HHH) shall return to provider (RTP) Part A claims.  These A/B MACs shall not mail an MSN for these claims.  A/B MACs (B) and DME MACs shall return as unprocessable Part B provider submitted claims.  The A/B MACs (B) and DME MACs shall not mail an MSN for these claims. When returning these claims as unprocessable, the shared processing system shall use Claim Adjustment Gr oup Code (Group Code) CO  Contractual Obligation, Claim Adjustment Reason Code (CARC) 16 -  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Do not use this code for claims attachment(s)/other documentati on.  At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present with Remittance Advice Remark Codes (RARCs) MA27 -  Missing/incomplete/invalid entitlement number or name shown on the claim and N382 -  Missing/incomplete/invalid patient identifier.  For assigned and non- assigned Part B claims submitted by the beneficiary on the Form CMS -1490S or Form CMS -1500, A/B MACs (B) and DME MACs shall manually return the claim in accordance with Pub.100- 04, Chapter 1, Section 80.3.2 A. "Special Considerations."