Saturday, August 23, 2014

Medicare unprocessable claim, incomplete information, invalid information claim process method.

Unprocessable Claim Rejections And Corrections

The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) describes an unprocessable claim as "Any claim with incomplete or missing, required information or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally."

Medicare defines incomplete information as required or conditional information that is missing from the claim. A few examples of incomplete information include missing a National Provider Identifier (NPI), a procedure code, or a date of birth.

Unprocessable claims also include those claims that contain incorrect or illogical information. This includes an incorrect NPI, an incorrect Health Care Identification Number (HICN), or the incorrect spelling of the patient's name.

Some other types of incorrect or invalid information that cause unprocessable claims include invalid procedure, ICD-9, or place of service codes.

When a Medicare claim contains incomplete or invalid information, it may be returned as unprocessable. Because Medicare was unable to complete processing and make an initial determination on the claim, there are no appeal rights available. These claims must be corrected and resubmitted.

Claims returned as unprocessable appear on the remittance advice with a MA130 code and an additional remark code identifying what must be corrected before resubmitting the claim.

To assist you in making the appropriate corrections, we provide you with the following information if it is available:

beneficiary's name;
dates of service; and
claim control number
Some of the top reasons claims are returned as unprocessable include:

Invalid/missing rendering physician

This rejection indicates the rendering physician is a member of a group and the individual physician information was not entered correctly or is missing.

Invalid/missing modifier

Possible reasons for rejection:

The modifier/procedure code combination may not be valid for Medicare;

The modifier is not valid for Medicare;
The modifier is not yet valid for Medicare.

For help with a missing or invalid modifier rejection, check the Physician Fee Schedule Relative Value File. This file may indicate whether certain modifiers are billable with the procedure code.

Verify whether the modifier is required or not when billing, that it is current and active.

Missing referring/attending physician

If you receive this rejection, check items(s) 17 and 17B of the CMS 1500 claim form or loops 2310A NM103 (DN) and 2310A NM109 (XX) of your electronic claim. This is a conditional field because not all services require a referring/attending physician. Services that may require this information include:

Immunosuppressive drug claims,
Diagnostic laboratory services,
Diagnostic radiology services,
Portable x-ray services, and
Durable Medical Equipment.
Missing Clinical Laboratory Improvement Act (CLIA) number
If the CLIA number is missing in item 23D of the CMS 1500 claim form or in Loop 2300 REF02(X4) of your electronic claim, we are unable to process the claim.

Missing address of facility

Facility is missing or incomplete in item 32 or electronic loop 2310C. Facility with a 9 digit zip code must be present if different than the billing address. Facility address is also required with Place of Service (POS) 12, patient's home. An NPI is not required for item 32A of the CMS 1500 claim for or electronic loop 2310C NM109, however if the information is entered, it must be correct.

Medicare Secondary Payer (MSP) information

Required MSP information is different for paper and electronic claim submitters. Paper claim submitters must indicate "None" in item 11 if Medicare is the primary payer. Electronic claim submitters need to do one of two things: all loops (2320 SBR03, 2320 SBR09, 2320 DMG02, 2320 DMG03, 2330A NM109, 2000B SBR05 and 2320 SBR 04) for other health insurance information must be complete if a beneficiary has other health insurance information, or if they do not have other health insurance, leave all fields blank.

Dates of charges missing (a quantity issue)

This rejection does not always indicate the from date of service is missing. Sometimes it is an indication there is a quantity billed issue. Typically, a service was quantity billed and could not be or should have been and was not.

For instance, a claim contains 2 numbers of services with a single date of service, but Medicare only recognizes that service with 1 number of service.

Health Insurance Claim Number (HICN) not entitled

The beneficiary's HICN is not entitled. Verify the information on the beneficiary's Medicare card. The information submitted to Medicare must appear exactly as it is on the beneficiary's Medicare card or the claim will reject as unprocessable.

Invalid/procedure modifier

This can mean the procedure code/modifier combination is invalid or the procedure code or modifier is invalid. Check Medicare policy, the Relative Value File, and current CPT guidelines to verify the procedure, modifier and/or the combination are valid for the date of service.

Truncated diagnosis code

Diagnosis codes submitted to Medicare must be of the greatest level of specificity. This means if there is a 5-digit diagnosis code, do not submit a 3 or 4-digit diagnosis code on the claim.

Invalid/incorrect diagnosis code

Verify the diagnosis code is valid for the date of service on the claim.

Missing initial date of treatment

This rejection is specific to chiropractic claims and indicates the initial date of treatment is missing

Physician Assistant, Nurse Practitioner, or Clinic Nurse Specialist is not associated with the billing provider

Verify the information submitted on the claims. If it is correct, contact provider enrollment to update the provider files before resubmitting the claim.

Incomplete or Invalid Claims Processing Terminology

The following definitions apply to §80.3.2. For carriers the requirements apply to Part B assigned and unassigned claims (Form CMS-1500) or electronic data interchange equivalent.

Unprocessable Claim - Any claim with incomplete or missing, required information, or any claim that contains complete and necessary information; however, the information provided is invalid. Such information may either be required for all claims or required conditionally.

Incomplete Information - Missing, required or conditional information on a claim (e.g., no Unique Physician Identification Number (UPIN) / Provider Identification Number (PIN) or National Provider Identifier (NPI) when effective).

Invalid Information - Complete required or conditional information on a claim that is illogical, or incorrect (e.g., incorrect UPIN/PIN or NPI when effective), or no longer in effect (e.g., an expired number).

Required - Any data element that is needed in order to process a claim (e.g., Provider Name, Date of Service).

Not Required - Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., Patient’s Marital Status).

Conditional - Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, then the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, then the insured’s name must be entered on a claim).

Return as Unprocessable or Return to Provider (RTP)- Returning a claim as unprocessable to the provider (RTP) does not mean that the carrier or FI should physically return every claim it received with incomplete or invalid information. The term “return to provider” is used to refer to the many processes utilized today for notifying the provider or supplier of service that their claim cannot be processed, and that it must be corrected or resubmitted. Some (not all) of the various techniques for returning claims as unprocessable include:

• Incomplete or invalid information is detected at the front-end of the carrier or FI claims processing system. The claim is returned to the provider (RTP’d) either electronically or in a hardcopy/checklist type form explaining the error(s) and how to correct the errors prior to resubmission. Claim data are not retained in the system for these RTP'd claims. No RA is issued.

• Incomplete or invalid information is detected at the front-end of the claims processing system and is suspended and developed. If requested corrections and/or medical documentation are submitted within a 45-day period, the claim is processed. Otherwise, the suspended portion is returned and the supplier or provider of service is notified by means of the RA.

• Incomplete or invalid information is detected within the claims processing system and is rejected through the remittance process. Suppliers or providers of service are notified of any error(s) through the remittance notice and how to correct prior to resubmission. A record of the claim is retained in the system (NOTE: This applies to carriers only. FIs do not use the remittance advice process for return to provider (RTP)).

A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal rights.

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