CMS 1500 Claim Form

Unprocessable Claim Rejections and Corrections

Assigned and nonassigned services are considered unprocessable when incomplete or invalid information is detected in our claims processing system.

Unprocessable claim is described in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1 as:

"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."

Identifying Unprocessable Services

An unprocessable service is rejected using one of the following methods:

  • Message code MA130 appears on your remittance advice indicating the claim is unprocessable.
  • Paper claims are screened and if information needed to process the claim is missing, the claim is mailed back to you with a form letter indicating why the claim is being returned.
  • Electronic claims that fail initial edits will be returned via the acceptance report.

If a claim contains both processable and unprocessable services, the unprocessable services are split onto a separate claim and returned as unprocessable.

Correcting Unprocessable Claims

Unprocessable claims must be corrected and retransmitted/resubmitted as new claims. There are no appeal rights on unprocessable claims (telephone or written). No appeal rights are afforded to these claims because no initial determination was made. The appeals process is only available when a complete and correct claim has been submitted and Medicare has processed a payment or denial. You should not call the reopening line or send a review request form to the appeals department as these claim cannot be reopened or appealed as they have no appeal rights.

To assist you in making the appropriate corrections, we provide you with the following information on the remittance advice if it is available:

  • Beneficiary’s name
  • HICN or MBI
  • Dates of service
  • Claim control number
  • Patient’s account number (Item 26 of the CMS-1500 [02/12] claim form or electronic equivalent. This field is optional to assist the provider in patient identification.)

In addition to message code MA130, your remittance advice may also include other message codes informing you what information is missing, invalid or incomplete. Reason and remark code lists are available on the Washington Publishing Company website.

Some of the top reasons claims are returned as unprocessable include:

Reason/Remark Code on Remittance Advice Provider Action
17 = Payment adjusted because requested information was not provided or was insufficient/ incomplete. Additional information is supplied using the remittance advice remarks codes whenever appropriate. Resubmit the claim with the requested information.
31 = Patient cannot be identified as our insured Verify that the Medicare number submitted on the claim matches the Medicare number on the patient’s Medicare card, to include the suffix.
  • If the Medicare number submitted does not match the Medicare number on their card, resubmit the claim with the correct Medicare number.
  • If the numbers match, the patient needs to contact their local Social Security Office to correct the problem. When the correction has been made, resubmit the claim.
109 = Claim not covered by this payer/contractor.
You must send the claim to the correct payer/ contractor.		 Check Item 32 on the claim filed for the state in which services were rendered. If not rendered in Jurisdiction K (Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhone Island or Vermont), the provider will need to file the claim to that state in which the services were performed.

In the case of a DMEPOS item, the beneficiary’s permanent home address determines to which DME MACs the claim should be submitted.
B7 = This provider was not certified for this procedure/ service on this date of service. The provider should check their CLIA certificate number to make sure the laboratory service being billed is within the scope of their certificate type.
B11 = The claim/service has been transferred to the proper payer/ processor for processing. Claim service not covered by this payer/ processor. Check with the carrier that the claim has been transferred to, for example Travelers, United Mine Workers Medicare or a health maintenance organization.
B15 = Payment adjusted because this service/ procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. The procedure code billed must be billed with a primary code. The provider should check coding references for the primary and/or add-on code and resubmit the claim with both the primary and add-on code on the same claim.
MA130 = Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. Please submit a new claim with complete and correct information. Information is missing which is needed to process the claim. The provider should check the claim to make sure all information is complete.
N290 = Missing/incomplete/invalid rendering provider identifier The claim was filed with an invalid or missing rendering NPI.

Refile the claim with the valid rendering provider’s NPI in Item 24J of the CMS-1500 claim form. For assistance with obtaining NPIs.

NPI Registry: https://nppes.cms.hhs.gov
4 = The procedure code is inconsistent with the modifier used, or a required modifier is missing A common error among providers is billing an inappropriate modifier with a procedure code.For example, a claim is submitted with office visit, CPT code 99215-26.Modifier 26 should not be appended to evaluation and management codes.

Providers are encouraged to refer to educational references such as the CPT Standard Edition or the HCPCS manuals.
N265 = Missing/incomplete/ invalid ordering provider primary identifier.

N286 = Missing/incomplete/ invalid referring provider primary identifier.		 Providers can avoid this denial by following the below requirements and tips. Certain services and situations require the submission of the referring/ordering provider information including:
  • Medicare covered services and items that result from a physician’s order or referral;
  • Parenteral and enteral nutrition;
  • Immunosuppressive drug claims;
  • Hepatitis B claims;
  • Diagnostic laboratory services;
  • Diagnostic radiology services;
  • Portable x-ray services;
  • Consultative services;
  • Durable medical equipment;
  • When the ordering physician is also the performing physician (as often is the case with in-office clinical laboratory tests);
  • When a service is “incident to” the service of a physician or nonphysician practitioner, the name of the physician or nonphysician practitioner who performs the initial service and orders the nonphysician service must appear in Item 17 (or the electronic equivalent);
  • When a physician extender or other limited licensed practitioner refers a patient for consultative service, submit the name of the physician who is supervising the limited licensed practitioner in Item 17 (or the electronic equivalent).
When one of the above services or situations has been provided, providers must provide the following information on the claim submission:
  1. The referring/ordering provider’s name. This information must be located in Item 17 on the CMS-1500 claim form or the electronic equivalent. If this information is absent, an unprocessable claim denial will occur.
  2. The referring/ordering provider’s NPI. This information must be located in Item 17b on the CMS-1500 claim form or the electronic equivalent. If this information is absent, an unprocessable claim denial will occur. This has been required since May 23, 2008.

CMS-1500 Item 17
MA120 = Missing/incomplete/invalid CLIA certification number Entities that perform clinical laboratory tests must obtain certification through the state department of health. This is known as CLIA certification.

Your CLIA number must be submitted on claims for clinical laboratory tests, including tests that are classified as 'CLIA-waived.' Submit the CLIA certification number in Item 23 of the CMS-1500 claim form or the electronic equivalent.

Some clinical laboratory tests must also be submitted with HCPCS modifier QW. The FDA determines which laboratory tests are waived. Please note that not all CLIA-waived tests require HCPCS modifier QW.

Determine if the CPT code is a waived test by accessing the CMS CLIA web page.

Submit your corrected claim as a new claim. Claims that are missing required CLIA certification numbers are returned as unprocessable and must be submitted as new claims.
MA04 = Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

N480 = Incomplete/invalid Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).		 If Medicare is unable to read the EOB or if the legend identifying the primary insurance denial codes is not included, National Government Services is unable to process the claim to coordinate benefits.

“Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.”

Providers should resubmit the claim with the corrected primary insurance information.
M76 = Missing/incomplete/invalid diagnosis or condition Verify the diagnosis code is valid for the date of service on the claim. Diagnosis codes submitted to Medicare must be of the greatest level of specificity. This means if there is a five-digit diagnosis code, do not submit a three- or four-digit diagnosis code on the claim.
MA122 = Missing/incomplete/invalid initial treatment date This rejection is specific to chiropractic claims and indicates the initial date of treatment is missing.
M79 = Missing/incomplete/ invalid charge The charge submission for the procedure code listed on the claim is missing, incomplete, and/or an invalid charge amount.Providers are submitting claims without a line item charge amount.

Providers are required to submit a charge amount on all claim submitted to the Medicare contractor.To avoid this error, you should complete all applicable information on the claim.
MA112 = Missing/incomplete/invalid group practice information Verify the Items below from the CMS-1500 claim form or electronic equivalent are properly filled out then resubmit claim.
  • Item 33 - Enter the provider of service/supplier’s billing name, address, ZIP code and telephone number. This is a required field
  • Item 33A – Enter the NPI of the billing provider or group
  • Item 33B – Leave Item blank
For a provider who is not a member of a group practice (e.g. private practice), enter the NPI of the individual physician/practitioner.

If a group practice is billing, then the group NPI is reported.

In addition, enter the information for the performing provider of service who is a member of the group practice reported in Item 33 as follows:
  • Item 24I – Leave item blank
    • Item 24J -– Do not use the shaded portion. Enter the rendering provider’s NPI number in the lower portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not the supervising, enter the NPI of the supervisor in the lower portion.
MA114 = Missing/incomplete/invalid information on where the services were furnished. Enter the name and address, ZIP code of the service location for all services in Item 32 of the CMS-1500 claim form or electronic equivalent. Only one name, address and zip code may be entered in Item 32 of the paper claim form. (The electronic claim format allows reporting of multiple service locations, specific to the line level service.)

Providers of service (namely physicians) shall identify the supplier’s name, address, and ZIP code when billing for purchased diagnostic tests. When more than one supplier is used, a separate CMS-1500 claim form shall be used to bill each supplier.

If an independent laboratory is billing, enter the place where the test was performed.

Report the NPI of the service facility as soon as it is available using the electronic format or the CMS-1500 claim form.
M52 = Missing/incomplete/invalid "from" date(s) of service.

M59 = Missing/incomplete/invalid “to” date(s) of service		 There are two possible explanations for this claim to be returned as unprocessable:
  1. The claim was billed with multiple dates of service and one unit for a code that does not allow this. Please correct the date of service and submit the claim.
  2. The claim was billed with multiple services on one line, and Medicare does not accept that many services per line. Please correct the date of service and submit the claim.

 

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