News

20-467 Changes and Clarifications to Reject Codes 76, AK and C6

Date: 06/02/20

See details on how to avoid rejections due to these common reject codes

Check the details as described under each reject code to correctly submit or resubmit claims. Participating providers must reflect complete and accurate data in all required fields on the Centers for Medicare & Medicaid Services (CMS)-1500 or UB-04 original Flint OCR Red, J6983 ink claim forms to be accepted as complete or clean claims. 

Confirm reject code 76 details before you resubmit the claim

Check for the original claim number in the correct box before submitting a second time. 

• When submitting a corrected claim on a UB-04 or CMS-1500, you must reference the original claim. Claim numbers can be found on your Remittance Advice (RA)/Explanation of Payment (EOP) or check claims status online.
• Refer to the original claim only on the UB-04 box 64 or CMS-1500 box 22 (Original Ref. No.).
• The frequency code (3rd digit of the bill type code on the UB-04) or resubmission code (CMS-1500 box 22 Resubmission Code) must be 7 or 8. If frequency/resubmission codes 7 or 8 are not used, leave boxes 64 and 22 (Original Ref. No.) blank.
• Do not include punctuation, words or special characters before or after the original claim number.
• The submission ID number from a reject letter is not a valid claim number.

Reject code AK clarification 

Leave UB-04 box 64 and CMS-1500 box 22 (Original Ref. No.) blank for a new claim. Any values entered in these boxes will cause the claim to reject when the claim is not a resubmitted claim. 

Reject code C6 – attach other insurance information, such as EOB, with the correct fields marked on the CMS-1500 to avoid rejections on paper claims

Get claims processed faster and avoid rejections with these guidelines when you fill out a CMS-1500 paper claim form for CalViva Health members who have other health insurance.

Include the health insurer’s EOB with these filled-in fields

• Enter the required information on the claim form in fields:

           - 9, 9a and 9d. 

            - Mark ‘yes’ in 11d. 

• Send the other health insurer’s explanation of benefits (EOB) with the claim. 

Do not include the participating physician group’s (PPG’s) EOB, denial or correspondence with the claim if the member does not have any other health insurance coverage.

This will cause the claim to reject and require it to be resubmitted without PPG attachments.

Waivers for timely filing and showing good cause

When a claim is denied for timely filing and a provider can show good cause for the delay, the plan accepts and processes the claim as if it was sent in a timely manner. The CHWP’s Provider Appeals Unit considers and makes the determination whether or not there is a good cause for the delay using standardized guidelines.

Good cause for delay guidelines

Good cause for delay applies when providers receive misinformation from members or Health Net and it causes timely filing claim denials. Providers must then show good cause for claim submission delays within these guidelines.

The delay was not reasonably in the provider's sole ability to control. For example: The provider received misinformation from the member and the provider is submitting one of the following: 

• Patient information form and/or member identification (ID) card shown by the member.
• EOB is from an incorrect carrier and/or PPG.
• The provider has followed Health Net instructions.
• Unforeseen circumstances existed that the provider could not prevent.
• In the normal course of business, the length of the delay made it hard for the provider to file the claim in a timely manner.
•  The delay was not the result of the provider's negligent or willful action or inaction.

Other adjustments guidelines 

For providers who can show proof of claim timely filing, Health Net gives consideration to other provider claim adjustments with the below guidelines. 

The provider submits proof in the form of one of the following: 

• Electronic data interchange (EDI) confirmation that Health Net received and accepted the claim.
• Delivery confirmation evidence (for example, registered receipt or certified mail receipt to a Health Net address).
• Screen print from accounting software to show the date the claim was submitted. 

Additional information

As a reminder the best way for fast turnaround and claims accuracy is to submit medical claims electronically. 

Use the Provider Quick Reference Guide for more details to submit the claim. 

Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.