(Medicare Claims Processing Manual)

 Requests information or assistance from another contractor.  This includes requests for charge data from the carrier, or any other request for information from the carrier;    Develops Medicare Secondary Payer (MSP) information;    Requests information necessary for a coverage determination;    Performs sequential processing when an earlier claim is in development; and   Performs outside development as a result of a CWF edit.   80.3.1 - Incomplete or Invalid Claims Processing Terminology  (Rev. 1588; Issued:  09- 05-08; Effective/Implementation Date:  08 -18-08)  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conditional information on a claim that is illogical, or incorrect (e.g., incorrect UPIN/PIN or NPI when effective), or no longer in effect (e.g., an expired number).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., Patients 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 insurers group name and number must be entered on a claim or if the insured is different from the patient, then the insur eds 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 ut ilized 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 c laims 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 (RTPd) either electronically or in a hardcopy/checklist type form explaining the error(s) and how to corre ct 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, t he 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 resu bmission.  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.  80.3.2 - Handling Incomplete or Invalid Claims  (Rev.: 4388; Issued: 09- 06-19; Effective: 10 -07-19; Implementation: 10 -07-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Claims processing specifications describe whether a data element is required, not required, or conditional (a data element which is required when certain conditions exist).  The status of these data elements will affect whether or not an incomplete or invalid claim (hardcopy or electronic) will be "returned as unprocessable" by the A/B MAC (B) or returned to provider (RTP) by the A/B MAC (A).  The contractor shall not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.  (See 80.3.1 for Definitions.)   If a data element is required and it is not accurately entered in the appropriate field, the contractor returns the claim to the provider of service.    If a data element is required, or is conditional (a data element that is required when certain conditions exist) and the conditions of use apply) and is missing or not accurately entered in its appropriate field, the contractor shall return as unprocessabl e or RTP the claim to either the supplier or provider of service.  NOTE:   Effective for claims with dates of service (DOS) on or after the implementation date of the ordering and referring phase 2 edits, Part B clinical lab and imaging technical or global component claims, Durable Medical Equipment, Prosthetics, claims and Hom e Health Agency (HHA) claims shall be denied, in accordance with CMS -6010- F final rule published on April 24, 2012, if the ordering or referring providers information is invalid or if the provider is not of a specialty that is eligible to order and r efer.   If a claim must be returned as unprocessable or RTP for incomplete or invalid information, the contractor shall, at minimum, notify the provider of service of the following information:   o Beneficiarys Name;   o Medicare beneficiary identifier ;  o Dates of Service (MMDDCCYY) (Eight -digit date format effective as of October 1, 1998);   o Patient Account or Control Number (only if submitted);   o Medical Record Number (FIs only, if submitted); and  o Explanation of Errors (e.g., Remittance Advice Reason and Remark Codes)   NOTE:   Some of the information listed above may in fact be the information missing from the claim.  If this occurs, the contractor includes what is available.   Depending upon the means of return of a claim, the supplier or provider of service has various options for correcting claims returned as unprocessable or RTP for incomplete or invalid information.  They may submit corrections either in writing, on- line, or  via telephone when the claim was suspended for development, or submit as a corrected claim or as an entirely new claim if data from the original claim was not retained in the system, as with a front -end return, or if a remittance advice was used to retu rn the claim. The chosen mode of submission, however, must be currently supported and appropriate with the action taken on the claim.   NOTE:   The supplier or provider of service must not be denied any services (e.g., modes of submission or customer service), other than a review, to which they would ordinarily have access.    If a claim or a portion of a claim is returned as unprocessable or RTP for incomplete or invalid information, the contractor does not generate an MSN to the beneficiary.    The notice to the provider or supplier will not contain the usual reconsideration notice, but will show each applicable error code or equivalent message.    If the contractor uses an electronic or paper remittance advice notice to return an unprocessable claim, or a portion of unprocessable claim:   1.   The remittance advice must demonstrate all applicable error codes.  At a minimum there must be a CARC/RARC combination that is compliant with CAQH CORE Business Scenario Two.   2.   The returned claim or portion must be stored and annotated, as such, in history, if applicable.  If contractors choose to suspend and develop claims, a mechanism must be in place where the contractor can re- activate the claim or portion for final adjudication.  A.  Special Considerations    If a suspense system is used for incomplete or invalid claims, the contractor will not deny the claim with appeal rights if corrections are not received within the suspense period, or if corrections are inaccurate.  The contractor must return the unproce ssable claim, without offering appeal rights, to the provider of service or supplier.   For assigned and unassigned claims submitted by beneficiaries (Form CMS -1490S), that are incomplete or contain invalid information, contractors shall manually return the claims to the beneficiaries.  If the beneficiary furnishes all other information but fails to supply the provider or suppliers NPI, and the contractor can determine the NPI using the NPI registry, the contractor shall continue to process and adjudicate the claim.  If the contractor determines that the provider or supplier was not a Medica re enrolled provider with a valid NPI, the contractor shall follow previously established procedures in order to process and adjudicate the claim.  Contractors shall send a letter to the beneficiary with information explaining which information is missing, incorrect or invalid; information explaining the mandatory claims filing requirements; instructions for resubmitting the claim if the provider or s upplier refuses to file the claim, or enroll in Medicare, and shall include language encouraging the beneficiary to seek non -emergency care from a provider or supplier that is enrolled in the Medicare program.  Contractors shall also notify the provider or supplier about his/her obligation to submit claims on behalf of Medicare beneficiaries and that providers and suppliers are required to enroll in the Medicare program to receive reimbursement.  Contractors shall consider a complete claim to have all items on the Form CMS -1490S completed along with an itemized bill with the following information: date of service, place of service, description of each surgical or medical service or supply furnished; charge for each service; treating doctors or suppliers name and address; diagnosis code; procedure code and the provider or suppliers NPI. The ordering & referring providers legal name and address and the National Provider Identifier (NPI) if known m ust be included on the itemized bill if from a Clinical laboratory for ordered tests; an independent diagnostic imaging center for ordered imaging procedures or a supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for order ed DMEPOS.  Required information on a claim must be valid for the claim to be considered as complete.   If a beneficiary submits a claim on the Form CMS -1500, return the Form CMS -1500 claim to the beneficiary, and include a copy of the Form CMS -1490S, along with a letter instructing the beneficiary to complete and return the Form CMS -1490S for processing within the time period prescribed in 70.5 above.  Include in the letter a description of missing, invalid or incomplete items required for the Form CMS -1490S that were not included with the submitted Form CMS -1500 or were invalid.   NOTE:   Telephone inquiries are encouraged.    Contractors shall not return an unprocessable claim if the appropriate information for both required and conditional data element requirements other than an NPI when the NPI is effective is missing or inaccurate but can be supplied through internal fil es.  Contractors shall not search their internal files to correct missing or inaccurate required and conditional data elements required under Sections 80.3.2.1.1 through 80.3.2.1.3 and required for HIPAA compliance for claims governed by HIPAA.   For either a paper or electronic claim, if all required and conditional claim level information that applies is complete and entered accurately, but there are both clean and dirty service line items, then split the claim and process the clean ser vice line item(s) to payment and return as unprocessable the dirty service line item(s) to the provider of service or supplier .  NOTE:   This requirement applies to carriers only.