Key Data Elements for EMC 837: Ensuring Medicare Claim Compliance
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Must require Date elements EMC 837
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 Identifiers (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 (8/05). Carriers are referred to the Health Care Claims Professional 837 Implementation guide for requirements for professional claims subject to HIPAA, including the NPI reporting requirements.
Carriers must return a claim as unprocessable to a provider of service or supplier and use the indicated remark code, or select and use another appropriate remark code, if the claim is returned through the remittance advice or notice process. In most cases, reason code 16, "Claim/service lacks information that is needed for adjudication", will be used in tandem with the appropriate remark code that specifies the missing information.
Carriers shall return a claim as unprocessable:
1. If a claim lacks a valid Medicare Health Insurance Claim Number (HICN) in item 1a. or contains an invalid HICN in item 1a. (Remark code MA61.)
2. If a claim lacks a valid patient’s last and first name as seen on the patient’s Medicare card or contains an invalid patient’s last and first name as seen on the patient’s Medicare card. (Remark code MA36.)
3. If a claim does not indicate in item 11 whether or not a primary insurer to Medicare exists. (Remark code MA83 or MA92.)
4. If a claim lacks a valid patient or authorized person’s signature in item 12 or contains an invalid patient or authorized person’s signature in item 12. (See “Exceptions,” bullet number one. Remark code MA75.)
5. If a claim lacks a valid “from” date of service in item 24A or contains an invalid “from” date of service in item 24A. (Remark code M52.) 6. If a claim lacks a valid place of service (POS) code in item 24B or contains an invalid POS code in item 24B, return the claim as unprocessable to the provider or supplier. Effective for claims received on or after April 1, 2004, on the Form CMS-1500, if a claim contains more than one POS (other than Home – 12), for services paid under the MPFS and anesthesia services.
Effective January 1, 2011, for claims processed on or after January 1, 2011 on the Form CMS-1500, if a claim contains more than one POS, including Home – 12, (or any POS contractors consider to be Home), for services paid under the MPFS and anesthesia services.
(Remark code M77.)
7. If a claim lacks a valid procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D or contains an invalid or obsolete procedure or HCPCS code (including Levels 1-3, “unlisted procedure codes,” and “not otherwise classified” codes) in item 24D. (Remark code M20 or M51.)
NOTE: Level 3 HCPCS are not valid under HIPAA after Dec 31, 2003.
8. If a claim lacks a charge for each listed service. (Remark code M79.)
9. If a claim does not indicate at least 1 day or unit in item 24G (Remark Code M53.) (Note: To avoid returning the claim as “unprocessable” when the information in this item is missing, the carrier must program the system to automatically default to “1” unit).
10. If a claim lacks a signature from a provider of service or supplier, or their representative. (See “Exceptions,” bullet number one; Remark code MA70 for a missing provider representative signature, or code MA81 for a missing physician/supplier/practitioner signature.)
11. If a claim does not contain in item 33:
a. A billing name, address, ZIP Code, and telephone number of a provider of service or supplier. (Remark code N256 or N258.)
b. A valid PIN number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05) when the NPI is required) for the performing provider of service or supplier who is not a member of a group practice. (Remark code N257)
c. A valid group PIN (or NPI when required) number or, for DMERC claims, a valid National Supplier Clearinghouse number (NPI in item 33a. of the Form CMS-1500 (8/05), when the NPI is required) for performing providers of service or suppliers who are members of a group practice. (Remark code N257)
12. If a claim does not contain in Item 33a., Form CMS 1500 (08-05), the NPI, when required, of the billing provider, supplier, or group. (Remark Code N257 or MA112.)
13. Effective May 23, 2008, if a claim contains a legacy provider identifier, e.g., PIN, UPIN, or National Supplier Clearinghouse number. (Remark Code N 257)
NOTE: Claims are not to be returned as unprocessable in situations where an NPI is not required (e.g., foreign claims, deceased provider claims, other situations as allowed by CMS in the future) and legacy numbers are reported on the claim. Such claims are to be processed in accordance with the established procedures for these claims.