(Medicare Claims Processing Manual)

A/B MACs (B) must return claims as unprocessable if they do not adhere to these requirements.   2 - Electronic Claims   A/B MACs (B) must return all electronic claims that do not include an 8 -digit birth date (CCYYMMDD) when a date is reported.    The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N329  MSN: N/A  If A/B MACs (B) do not currently edit for birth date items because they obtain the information from other sources, they are not required to return these claims if a birth date is reported in items 3, 9b., or 11a. and the birth date is not in 8- digit format.  However, if A/B MACs (B) do use date of birth information on the incoming claim for processing, they must edit and return claims that contain birth date(s) in any of these items that are not in 8- digit format.   B - Required Data Element Requirements   The following Medicare -specific, return as unprocessable  requirements in this section and the following two sections are in addition to requirements established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Regulations implementing HIPAA require the use of National Provider Ide ntifiers (NPIs) by covered health care providers and health plans. Although not required by HIPAA, CMS is extending the requirement to include the NPI on electronic claims to paper claims submitted on the Form CMS -1500.  A/B MACs (B) are referred to the He alth Care Claims Professional 837 Implementation guide for requirements for professional claims subject to HIPAA, including the NPI reporting requirements.  A/B MACs (B) must return a claim as unprocessable to a provider of service or supplier and use the indicated remittance advice codes.   Carriers shall return a claim as unprocessable:   1. If a claim lacks a valid Medicare beneficiary identifier in item 1a. or contains an invalid Medicare beneficiary identifier in item 1a.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N382  MSN: N/A  80.3.2.1.2 - Conditional Data Element Requirements for A/B MACs and DME  MACs (Rev. 4473, Issued: 12- 6-19; Effective: 3 -9-20; Implementation: 3 -9-20)  A - Universal Requirements   The following instruction describes conditional data element requirements, which are applicable to certain assigned A/B MAC (B) claims.  This instruction is minimal and does not include all conditional data element requirements, which are universal for  processing claims.   Items from the Form CMS -1500 claim form have been provided.  These items are referred to as fields in the instruction.  A/B MACs (B) processing claims on the Form CMS -1500 shall return a claim as unprocessable to the supplier/provider of service in the following circumstances:   1.   If a service was ordered or referred by a physician, physician assistant, nurse practitioner, or clinical nurse specialist (other than those services specified in Claim Specific Requirements) and his/her name is not present in item 17 or if the NPI is  not entered in item 17b of the Form CMS -1500.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N285 (for missing name) or N286 (for missing identifier)  MSN: N/A   2.   If a physician extender or other limited licensed practitioner refers a patient for consultative services, but the name and/or NPI required of the supervising physician is not entered in items 17 or if the NPI is not entered in item 17b of the Form CM S-1500.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N269 (for missing name) or N270 (for missing identifier)  MSN: N/A   NOTE:   For item 80.3.2.1.2 - 1 above, e ffective for claims with dates of service (DOS) on or after the implementation date of the Phase 2 ordering and referring denial edits, a Part B clinical lab and imaging technical or global component claim or Durable Medical Equipment, Prosthetics, and Ort hotics Suppliers (DMEPOS) claim is denied when the ordering/referring provider not allowed to order/refer.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 183  RARC: N574, MA13 MSN: 21.6  The claim is denied when the first four letters of the last name provided on the ordering/referring providers claim does not match what is listed in the providers record.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N264, MA13, N575 MSN: 21.6  If the claim is submitted that lists an ordering/referring provider and the required matching NPI is not reported, then the claim shall be rejected. This is the only instance when a rejection is allowed.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 16  RARC: N265, MA13 MSN: N/A  For 3 through 12 below, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under these policies.   These CARC/RARC combinations compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: shown below.  MSN: N/A  3.   For the technical component and professional component of diagnostic tests subject to the anti -markup payment limitation:   a. If a YES or NO is not indicated in item 20 and no acquisition price is entered under the word $CHARGES.  A/B MACs (B) shall assume the service is not subject to the anti -markup payment limitation.  This claim shall not be returned as unprocessable  for this reason only.  b. If a Yes or No is not indicated in item 20 and an acquisition price is entered under the word $CHARGES.  RARC: MA110   c. If the YES box is checked in item 20 and a required acquisition price is not entered under the word $CHARGES.  RARC: MA111  d. If the NO box is checked in item 20 and an acquisition price is entered under the word $CHARGES. RARC: MA110  e. If the YES box is checked in item 20 and the acquisition price is entered under $CHARGES", but the performing physician or other suppliers name, address, ZIP Code, and NPI is not entered into item 32a of the Form CMS -1500 when billing for diagnostic  services subject to the anti -markup payment limitation.  RARC: N294   Entries f  k are effective for claims received on or after April 1, 2004:   f. On the Form CMS -1500, if the YES box is checked in Item 20, and more than one test is billed on the claim;  g. On the Form CMS -1500, if both the technical component and professional component are billed on the same claim and the dates of service and places of service do not match;   h. On the Form CMS -1500, if the YES box is checked in Item 20, both the technical component and professional component are submitted and the date of service and place of service codes do not match.   i. On the ASC X12 837 professional claim format, if there is an indication on the claim that a test is subject to the anti- markup payment limitation, more than one test is billed on the claim, and line level information for each total acquisition amount is not submitted for each test.   j. On the Form CMS -1500 if the YES box is checked in Item 20 and on the ASC X12 837 professional claim format if there is an indication on the claim that a test is subject to the anti- markup payment limitation, and the service is billed using a global code rather than having each component billed as a separate line item.   k. If there is an indication on the claim that the test is subject to anti- markup and the NPI of the performing entity (in Item 32a of the CMS -1500 or its ASC X12 837 equivalent) belongs to the billing provider OR the performing entity is not a valid, Medi care enrolled entity.   4.   If a provider of service or supplier is required to submit a diagnosis in item 21 and either the diagnosis code is missing, incorrect or truncated; or a narrative diagnosis was not provided on an attachment.  RARC: M76   5.   For claims received on or after April 1, 2013, if a provider of service or supplier is required to submit a diagnosis in Item 21 of the Form CMS - 1500 and an ICD -9-CM E code (external causes of injury and poisoning) is reported in the first field of  Item 21. And, effective for dates of service on or after the effective date for ICD -10-CM codes, if an ICD -10-CM diagnosis code within the code range of V00 through Y99 is reported in the first field of Item 21. RARC: MA63  For paper claims, ICD -10-CM codes can be reported only on the revised CMS -1500 claim form version 02/12, but not before the effective date of ICD -10-CM.  The revised form (02/12) has the capacity to accept either ICD -9-CM or ICD -10-CM codes depending upon the effective date of the ICD code set.  The old form version (08/05) had only the capacity to accept ICD -9-CM codes.   Refer to chapter 26 for more information about the old and revised forms).  6.   If a rendering physician, physician assistant, nurse practitioner, clinical nurse specialist, supplier/or other practitioner who is a sole practitioner or is a member of a group practice does not enter his/her NPI into item 24J of Form CMS -1500 except  for influenza virus and pneumococcal vaccine claims submitted on roster bills that do not require a rendering provider NPI.  RARC: N290  7.   If a primary insurer to Medicare is indicated in item 11, but items 4, 6, and 7 are incomplete.  Item 4: RARC: MA92.  Item 6: RARC: MA89.  Item 7: RARC: MA88.   8.   If there is insurance primary to Medicare that is indicated in item 11 by either an insured/group policy number or the Federal Employee Compensation Act number, but a Payer or Plan identification number (use HPID when effective) is not entered in field 11C (RARC: MA92), or the primary payers program or plan name when a Payer or Plan ID (use HPID when effective) does not exist (RARC: N245).  9.   If a HCPCS code modifier must be associated with a HCPCS procedure code or if the HCPCS code modifier is invalid or obsolete.  RARC: M20   10.   If a date of service extends more than 1 day and a valid to date is not present in item 24A.  RARC: M59   11.   If an unlisted procedure code or a not otherwise classified (NOC) code is indicated in item 24D, but an accompanying narrative is not present in item 19 or on an attachment.  RARC: M51