Disposition Code 55 (Personal Characteristic Mismatch)

20.3.3.6 - Disposition Code 55 (Personal Characteristic Mismatch) (Rev. 4047, Issued: 05-11-18, Effective: 08-13-18, Implementation: 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 beneficiary’s 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 beneficiary’s personal characteristics do not match the HICN in accordance with the CWF matching criterion, contractors shall return 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 Group 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 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 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."