12/11/2020

CGS Claim Payment Alert - Update on Claims Processed with Incorrect MUE Values

The following was announced in a CGS listserv on 12/11/20:

CGS has issued several status updates regarding claims processed with incorrect Medically Unlikely Edit (MUE) values.  Suppliers were advised to take no action as CGS worked to correct the claims impacted.  CGS has completed all actions to resolve the MUE processing errors.  All claims processed against the incorrect MUE values have now been adjudicated properly.   

Summary of the Issue

Initial claims and adjustments initiated or in process on 9/23/20 or 9/24/20 were adjudicated against the wrong MUE file.  Initial and adjusted claims were denied with reason code CO-151 and remark code MA01.  Adjustments executed during the time period automatically created overpayments.   

CGS Completed Actions

CGS has corrected all initially denied claims and adjusted claims processed with incorrect MUE values. 

• Initial denials
• The last 3 digits of the corrected claim numbers will most commonly end in 001. 
• Adjustment claims
• The last 3 digits of the claim numbers will most commonly end in 003.  

References & Resources

You may utilize the claim status portion of the myCGS web portal to view these adjustments and to determine allowed amounts.   

• Overpayment demand letters
• Not all CO-151 denials were processed incorrectly.  CGS has issued new demand letters for claims with valid CO-151 denials.  The date on the newly issued demand letters should be the date utilized for timely filing of appeals.    

References & Resources

The new demand letters have dates on or after 11/04/20.  Suppliers have 120 days from the date of the newly issued demand letter to request an appeal for situation in which you disagree with the final decision.

• Immediate offsets and supplier refunds
• Suppliers with overpayments immediately offset in error, due to the MUE issue, have been issued refunds.    

References & Resources

CGS has issued manual invoices for the refunds associated with the erroneous MUE immediate offsets.  The invoice number is populated with the associated claim number.  For identification on remittance notices, the PLB Reason Code field is populated with C5 (five). 

To review the details of actions taken by CGS to correct the MUE processing errors, visit the Submitting a Claim or Claim Payment Alerts page on our website. 

CGS apologizes for any inconveniences the processing errors may have caused.  Thank you for your patience as we completed the actions necessary to correct the impacted claims