evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
No workload count will be granted for the dirty service line portion of the claim returned as unprocessable.  The clean service line portion of the claim may be counted as workload only if it is processed through the remittance process .  Contractors must abide by the specifications written in the above instruction; return the dirty service line portion without offering appeal rights.    Workload will be counted for claims returned as unprocessable through the remittance process.  Under no circumstances should claims returned as unprocessable by means other than the remittance process (e.g., claims returned in the front -end) be reported in  the workload reports submitted to CMS.  The contractor is also prohibited from moving or changing the action on an edit that will result in an unprocessable claim being returned through the remittance process.  If the current action on an edit is to suspe nd and develop, reject in the front or back -end, or return in the mailroom, the contractor must continue to do so.  Workload is only being granted to accommodate those who have edits which currently result in a denial.  As a result, workload reports should not deviate significantly from those reports prior to this instruction.  NOTE:   Rejected claims are not counted as an appeal on resubmissions.   B.  Special Reporting of Unprocessable Claims Rejected through the Remittance Process (Carriers Only):
(Medicare Claims Processing Manual)
NOTE:   Rejected claims are not counted as an appeal on resubmissions.   B.  Special Reporting of Unprocessable Claims Rejected through the Remittance Process (Carriers Only):   A/B MACs (B) must report claims returned as unprocessable on a remittance advice on line 15 (Total Claims Processed) and on line 14 (subcategory Non- CWF Claims Denied) of page one of your Form CMS -1565.  Although these claims are technically not denials, line 14 is the only suitable place to report them given the other alternatives.  In addition, these claims should be reported as processed not paid other claims on the appropriate pages (pages 2 -9) of CROWD Form T for the reporting month in which the cl aims were returned as unprocessable through the remittance process.  Also, A/B MACs (B) report such claims on Form Y of the Contractor Reporting of Operational and Workload Data (CROWD) system.  They report the number of such claims returned during the month as unprocessable through the remittance process under Column 1 of Form Y on a line using code 0003 as the identifier.   If a supplier, physician, or other practitioner chooses to provide missing or invalid information for a suspended claim by means of a telephone call or in writing (instead of submitting a new or corrected claim), A/B MACs (B) do not report this activity as  a claim processed on Form CMS -1565/1566.  Instead, they subtract one claim count from line 3 of Form Y for the month in which this activity occurred.   EXAMPLE:  Assume in the month of October 2001 the carrier returned to providers 100 claims as unprocessable on remittance advices.  The carrier should have included these 100 claims in lines 14 and 15 of page 1 of your October 2001 Form CMS -1565.  During this same month, assume the carrier received new or corrected claims for 80 of the 100 claims returned during the month.  These 80 claims should have been counted as claims received in line 4 of your October 2001 Form CMS -1565 page one (and subsequently as processed claims for the reporting month when final determination was made).
(Medicare Claims Processing Manual)
Also, during October 2001, in lieu of a corrected claim from providers, assume the carrier received missing information by means of a telephone call or in writing for 5 out of the 100 claims returned during October 2001.  This activity should not have been reported as new claims received (or subsequently as claims processed when adjustments are made) on Form CMS -1565.  On line 3 of Form Y for October 2001, the A/B MAC (B) should have reported the number 95 (From claims returned as unprocessable through the remittance process minus 5 claims for which the carrier received missing or invalid information by means of a telephone call or in writing.  For the remaining 15 claims returned during October 2001 with no response from providers in that same month, the carrier should have reported on the Form CMS -1565 or Form Y, as appropriate, any subsequent activity in the reporting month that it occurred.  For any of these returned claims submitted as new or corrected claims, the A/B MAC (B) should have reported their number as receipts on line 4 of page one of Form CMS -1565.  For any of these returned claims where the supplier or provider of service chose t o supply missing or invalid information by means of a telephone call or in writing, the A/B MAC (B) should not have counted them again on Form CMS -1565, but subtracted them from the count of returned claims reported on line 3 of Form Y for the month this a ctivity occurred.   C.  Exceptions (A/B MACs (B)  Only)   The following lists some exceptions when a claim may not be returned as unprocessable for incomplete or invalid information.  A/B MACs (B) shall not return a claim as unprocessable:   If a patient, individual, physician, supplier, or authorized persons signature is missing, but the signature is on file, or if the applicable signature requirements have been met, do not return a claim as unprocessable where an authorization is attached t o the claim or if the signature field has any of the following statements (unless an appropriate validity edit fails):   Acceptable Statements for Form CMS -1500:    For items 12, 13, and 31, Signature on File statement and/or a computer generated signature;    For items 12 and 13, Beneficiarys Name By Representatives Signature;
(Medicare Claims Processing Manual)
 For items 12, 13, and 31, Signature on File statement and/or a computer generated signature;    For items 12 and 13, Beneficiarys Name By Representatives Signature;   For item 12, X with a witnessed name and address. (Chapter 26 for instructions.)   D.  Misdirected Claims   See 10.1.9 for instructions on handling claims that are submitted to the wrong contractor, or to the wrong payment jurisdiction.   80.3.2.1.1 - A/B MAC (B) Data Element Requirements  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  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.   A - Required Data Element Requirements   1 - Paper Claims   The following instruction describes certain data element formatting requirements to be followed when reporting the calendar year date for the identified items on the Form CMS -1500:    If birth dates are furnished in the items stipulated below, then these items must contain 8- digit birth dates (MMDDCCYY).  This includes 2- digit months (MM) and days (DD), and 4- digit years (CCYY).   Form CMS -1500 Items Affected by These Reporting Requirements:   Item 3 - Patients Birth Date   Item 9b - Other Insureds Date of Birth   Item 11a -  Insureds Date of Birth   Note that 8 -digit birth dates, when provided, must be reported with a space between month, day, and year (i.e., MM_DD_CCYY).  On the Form CMS -1500, the space between month, day, and year is delineated by a dotted, vertical line.   If a birth date is provided in items 3, 9b, or 11a, and is not in 8- digit format, carriers must return the claim as unprocessable.
(Medicare Claims Processing Manual)
If a birth date is provided in items 3, 9b, or 11a, and is not in 8- digit format, carriers must return the claim as unprocessable.    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 carriers 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.  Ho wever, if carriers 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.   For certain other Form CMS -1500 conditional or required date items (items 11b, 14, 16, 18, 19, or 24A.), when dates are provided, either a 6- digit date or 8- digit date may be provided.  If 8-digit dates are furnished for any of items 11a., 14, 16, 18, 19, or 24A. (excluding items 12 and 31), carriers must note the following:    All completed date items, except item 24A., must be reported with a space between month, day, and year (i.e., MM_DD_CCYY).  On the Form CMS -1500, the space between month, day, and year is delineated by a dotted, vertical line;    Item 24A. must be reported as one continuous number (i.e., MMDDCCYY), without any spaces between month, day, and year.  By entering a continuous number, the date(s) in item 24A. will penetrate the dotted, vertical lines used to separate month, day, and yea r.  Carrier claims processing systems will be able to process the claim if the date penetrates these vertical lines.  However, all 8 -digit dates reported must stay within the confines of item 24A;
(Medicare Claims Processing Manual)
 Do not compress or change the font of the year item in item 24A. to keep the date within the confines of item 24A.  If a continuous number is furnished in item 24A. with no spaces between month, day, and year, you will not need to compress the year item to remain within the confines of item 24A.;    The from date in item 24A. must not run into the to date item, and the to date must not run into item 24B.;    Dates reported in item 24A. must not be reported with a slash between month, day, and year; and    If the provider of service or supplier decides to enter 8- digit dates for any of items 11b, 14, 16, 18, 19, or 24A. (excluding items 12 and 31), an 8- digit date must be furnished for all completed items.  For instance, you cannot enter 8 -digit dates for it ems 11b, 14, 16, 18, 19 (excluding items 12 or 31), and a 6 -digit date for item 24A.  The same applies to those who wish to submit 6- digit dates for any of these items.   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.
(Medicare Claims Processing Manual)
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:
(Medicare Claims Processing Manual)
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.
(Medicare Claims Processing Manual)
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