CMS Pub. 100-04, ch. 1, § 120.3

Suspect duplicates are claims or claim lines that contain closely-aligned elements

sufficient to suggest that duplication may be present and, as such, require that the suspect

claim be reviewed. Suspect duplicate edits can be hard coded in the system or local edits

set up by Medicare contractors.

A. Criteria for Detecting Suspect Duplicates for Institutional Claims

A “suspect duplicate” claim is a claim being processed which, when compared to the

history or pending file, begins with these characteristics:

• Match on the beneficiary information;

• Match on provider identification, and

• Same date of service or overlapping dates of service.

The contractors examine and compare to the prior bill any bill that is identified as a

suspect duplicate. If the services (revenue or HCPCS codes) on a claim duplicate the

services for the other, contractors should check the diagnosis. If the diagnosis codes are

duplicates, obtain an explanation from the provider before making payment.

B. Suspect Duplicate Claims Submitted by Physicians and other Suppliers

(including DMEPOS Claims)

The criteria for identifying suspect duplicate claims submitted by physicians and other

suppliers are not published and vary according to the type of billing entity, type of item

or service being billed, and other relevant criteria. The denial of claim as a duplicate of

another claim may be appealed when the denial is based on criteria other than those

specified above for exact duplication.

A/B MACs, Part B legacy contractors, and DME MACs must add an informational

indicator to the Common Working File (CWF) transaction record when, as a result of a

contractor audit/edit or CWF reject, the contractor examines what appears to be a

duplicate item or service and approves it for payment.