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Elizabeth M. Whitehorn, Director

DHS/DMH and SASS Claims Submitted

HFS System Issue:

DHS/DMH and SASS claims submitted by Community Mental Health Centers are either paying incorrectly or rejecting with the A59 - Procedure/Modifier/POS Combination Invalid - error code.

Additionally, some DHS/DMH claims submitted by Community Mental Health Centers for FY’17 dates of service are receiving the D04 - Suspended for Department Review - error code.  This is an informational only error message and claims will continue to process and adjudicate once the hold edit is lifted.

Problem:

The Department is working to implement coding and system modifications, causing claims to either pay incorrectly or reject in error.  The DHS/DMH claims receiving the D04 informational error message are being held pending implementation of contractual funding information, as well as implementation of coding and system modifications.

Providers Impacted:

Community Mental Health Centers enrolled as provider type 036.

Procedure Codes Impacted:

All

Problem Begin Date:

Incorrect payments or A59 rejections - July 2016

D04/Suspended for Department Review – July 1, 2016 for FY’17 claims with dates of service on or after 7/1/16

Problem Fix Date:

A59 rejection or incorrect payment – September 1, 2016.

D04 – contractual funding information was loaded on September 29, 2016.  All held claims were released into processing for re-editing and final adjudication on September 30, 2016.

Resolution for Impacted Claims:

Claims that paid incorrectly will be reprocessed by the Department.  Providers must resubmit claims that rejected A59.

Claims with FY’17 dates of service for which providers received the D04/’Suspended for Department Review’ informational message were released into processing for re-editing.  Providers will receive remittance advice showing claim status following final adjudication.  Providers do not need to resubmit unless claims require correction and resubmission due to errors received during final adjudication.