Reason Code 34963

Published 06/27/2023

Reason Code 34963
The Attending Physician on Claim Page 05 is invalid or not present in the Provider Enrollment Chain and Ownership System (PECOS) Enrolled Physicians file, Type C Records. Or, the Attending Physician NPI is present on the PECOS Enrolled Physicians file but the first four digits of the last name do not match. Or, the claim has a Through Date of Service equal or greater than the Termination Date on the PECOS Enrolled Physician Inquiry screen (MAP1B52).

Effective for claims received on or after April 1, there is a new consistency edit that validates the attending provider NPI. Organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met. Information has been added to explain how the attending physician information on a claim is verified.

Common Reason Code Errors

  • Claim submitted with an attending physician NPI number that is not valid in PECOS
  • Claim submitted with a name not matching the first initial of the first name, and first four letters of the last name (common with maiden names and newly hyphenated names)
  • Claim submitted with an organizational NPIs in place of individual attending physicians NPI
  • Claim submitted with an NPI for a physician or nonphysician practitioner specialties that is not eligible as an attending physician enrolled in PECOS in an approved status. Valid values are:
    • Doctor of medicine or osteopathy
    • Dental surgery (19)
    • Podiatric medicine (48)
    • Optometry (41)
    • Chiropractic medicine (35)
    • Physician assistant (97)
    • Certified clinical nurse specialist (89)
    • Nurse practitioner (50)
    • Clinical psychologist (68)
    • Certified nurse midwife (42)
    • Licensed clinical social worker (80)
    • Certified registered nurse anesthetist (43)
    • Registered dietitian/nutritional professional (71)

Resolution

  • Verify that the attending provider NPI is enrolled in PECOS
  • Verify that the attending provider name is submitted on claims as listed in PECOS
  • Verify that the attending physician NPI submitted is a valid specialty from the list above, and not a group or organizational NPI

Resource: MLN Matters Article 12889 (PDF).


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