(Medicare Claims Processing Manual)

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   12. If the name, address, and ZIP Code of the facility where the service was furnished in a hospital, clinic, laboratory, or facility other than the patients home or physicians office is not entered in item 32 (Remark code MA114 is used.)  Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered. RARC: MA114  Effective for claims with dates of service on or after October 1, 2007, the name, address, and 9 -digit ZIP Code of the service location for services paid under the Medicare Physician Fee Schedule and anesthesia services, other than those furnished in place of service home  12, and any other places of service A/B MACs treat as home, must be entered according to Pub. 100- 04, Chapter 1, sections 10.1.1 and 10.1.1.1.  RARC: MA114  Effective for claims with dates of service on or after October 1, 2007, f or claims received that require a 9 -digit ZIP Code with a 4 digit extension, a 4- digit extension that matches one of the ZIP9 file or a 4 -digit extension that can be verified according to Pub. 100- 04, Chapter 1, sections 10.1.1 and 10.1.1.1 must be entered on the claim.  RARC: MA114   Effective January 1, 2011, for claims processed on or after January 1, 2011, on the Form CMS -1500, the name, address, and 5 or 9- digit ZIP code, as appropriate, of the location where the service was performed for services paid under the Medicare Physician Fee Schedule and anesthesia services, shall be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 for services provided in all places of service.  RARC: MA114  Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional electronic claim format for services payable under the MPFS and anesthesia services when rendered in POS home (or any POS th ey consider home) if submitted without the service facility location.  RARC: MA114  13. Effective for claims received on or after April 1, 2004, if more than one name, address, and ZIP Code is entered on the Form CMS -1500 in item 32.   14. If any of the modifiers PA, PB, or PC are incorrectly associated with a service which is other than a wrong surgery on a patient, surgery on the wrong body part, surgery on the wrong patient or a service related to one of these surgical errors.   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: 4  RARC: N/A  MSN: N/A  80.3.2.1.3 - A/B MAC (B) Specific Requirements for Certain Specialties/Services  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  Unless otherwise specified, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under the policies in this section.   These CARC/RARC combinations compliant with CAQH CORE Business Scenario Tw o.  Group Code: CO  CARC: 16  RARC: shown below.  MSN: N/A   A/B MACs (B) must return the following claim as unprocessable to the provider of service/supplier:   A.   For chiropractor claims:   1.   If the x- ray date is not entered in item 19 for claims with dates of service prior to January 1, 2000.  Entry of an x- ray date is not required for claims with dates of service on or after January 1, 2000.  2.   If the initial date actual treatment occurred is not entered in item 14.  RARC: MA122  B.   For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and the groups name, address, and ZIP Code is not entered in item 33 or if the NPI is not entered in item 33a of the Form CMS -1500, if their personal NPI is not entered in item 24J of the Form CMS -1500.  RARC: MA112   C.   For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location where the order was accepted were not entered in item 32.  RARC: MA114   D.   For physicians who maintain dialysis patients and receive a monthly capitation payment:   1.   If the physician is a member of a professional corporation, similar group, or clinic, and the NPI is not entered into item 24J of the Form CMS -1500.  RARC: N290   2.   If the name, address, and ZIP Code of the facility other than the patients home or physicians office involved with the patients maintenance of care and training is not entered in item 32.  RARC: MA114.  Effective for claims received on or after Apr il 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered.   E.   For routine foot care claims, if the date the patient was last seen (RARC: N324) and the attending physicians NPI is not present in item 19 (RARC: N253).    F.   For immunosuppressive drug claims, if a referring/ordering physician, physicians assistant, nurse practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a. (RARC: N264), or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).  G.   For all laboratory services, if the services of a referring/ordering physician, physicians assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. (RARC: N264) or if the NPI is not e ntered in item 17b. of the Form CMS -1500 (RARC: N286).    H.   For laboratory services performed by a participating hospital -leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patients home or physicians office (including services to a patient in an institution) , if the name, address, and ZIP Code of the location where services were performed is not entered in item 32.  RARC: MA114  Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services ot her than those furnished in place of service home  12 must be entered.   I.   For independent laboratory claims:   1.   Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., Homebound).  RARC: MA116  2.   If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patients home or physicians office.  RARC: MA114.  Effective for claims received on or after April  1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home  12 must be entered.   3.   When a diagnostic service is billed as an anti -markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a.  If Items 32 and 32a are not entered. RARC: MA114   J.   For mammography diagnostic and screening claims, if a qualified screening center does not accurately enter their 6 -digit, FDA -approved certification number in item 32 when billing the technical or global component.  RARC: MA128   K.   For parenteral and enteral nutrition claims, if the services of an ordering/referring physician, physician assistant, nurse practitioner, clinical nurse specialist are used and their name is not present in item 17 (RARC: N264) or if the NPI is not ent ered in item 17b. of the Form CMS -1500(RARC: N286).    L.   For portable x- ray services claims, if the ordering physician, physician assistant, nurse practitioner, clinical nurse specialists name, and/or NPI is not entered in items 17  (RARC: N264) or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).   M.   For radiology and pathology claims for hospital inpatients, if the referring/ordering physician, physician assistant, nurse practitioner, or clinical nurse specialists name, if appropriate, is not entered in item 17 (RARC: N264) or if the NPI is not entered in item 17b. of the Form CMS -1500 (RARC: N286).    N.   Effective for claims with dates of service on or after October 1, 2012, all claims for physical therapy, occupational therapy, or speech -language pathology services, including those furnished incident to a physician or nonphysician practitioner (NPP) services, must have the name and NPI of the certifying physician or NPP of the therapy plan of care.  For the purposes of processing professional claims, the certifying physician/NPP is considered a referring provider.  For paper billing, the certifying physician/NPP name and NPI is entered in Items 17 and 17b.  Providers and suppliers filing electronic claims are required to comply with applicable HIPAA ASC X12 837 claim completion requirements for reporting a referring provider.  (See Pub. 100- 04, chapter  5, 20 and Pub. 100- 02, chapter 15, 220 and 230 for therapy service policies.)   NOTE:   For items 80.3.2.1.3 (g), (k), (l), (m),  and (n) above, e ffective for claims with dates of services (DOS) on or after the implementation date of the Phase 2 ordering and referring denial edits, the Part B clinical lab and imaging technical or global component claim, or Durable Medical Equipment, Prosthetics, and Orthotics Suppliers (DMEPOS) claim is denied due to the ordering/referring provider not allowed to order/refer.   For item N only: 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  MSN: N/A  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. RARC: N264