Tuesday, June 22, 2010

CMS 1500 - Claim error

Claim Errors

“Unprocessable claims” is a term used by Medicare for claims that contain certain incomplete or invalid
information and are returned to the provider. For example, a claim may be returned as unprocessable because the contractor requires additional information or a correction to the submitted claim data. Because there is no initial determination on the claim, health care professionals and suppliers who submit unprocessable claims have no appeal rights. The phrase “return as unprocessable” does not mean that in every case a claim is physically returned. Contractors may return the actual unprocessable claim (or a copy of it) to the health care professional or supplier with a letter of explanation or generate a Remittance Advice (RA), which we will discuss later in this fact sheet. Some contractors may suspend a claim that contains incomplete or invalid information, and then provide notice of the errors to the provider and afford a period of time for corrections to be submitted. When adequate corrections are submitted, the contractor will then resume processing of the claim.

Providers need to be aware that an unprocessable claim that has been returned for correction and resubmission does not toll the timely filing period. A correct claim must be resubmitted within the timely filing period. Where a contractor has suspended a claim and allowed a period for submission of corrections, the timely filing requirements will have been met if the corrections are received within the allotted time.Form CMS-1500 incomplete and invalid claims processing guidelines may be found in the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c01.pdf

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