Tuesday, June 22, 2010

Returned or unprocessable claim - cms 1500

Returned Claims
Please correct “returned” claims promptly because only when this is done will a provider have met his legal obligation for submitting a Medicare claim.

Definitions
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 National Provider Identifier (NPI)).

Invalid Information – Complete required or conditional information on a claim that is illogical or incorrect (e.g., incorrect NPI) or no longer in effect (e.g., an expired number).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., patient’s marital status).

Conditional – Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, the insured’s name must be entered on the claim).

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