Top Reasons for Unprocessable Claims
National Government Services has composed a list of the top reasons for returning claims as unprocessable; due to missing, incomplete, insufficient or invalid claim information.
An unprocessable claim is described in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (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."
Claims processing specifications describe whether a data element is required, not required, or conditional (a data element which is required when certain conditions exist). The status of these data elements will affect whether or not an incomplete or invalid claim (hardcopy or electronic) will be "returned as unprocessable" or “returned to provider” (RTP). A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal rights.
Top Reasons for RTP
- Missing or invalid insured Medicare ID number
- Missing diagnosis code
- Missing place of service code
- Missing service facility location
- Missing or invalid NPI format
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.
Correcting Unprocessable Claims
Unprocessable claims must be corrected and retransmitted/resubmitted as new claims.
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10
- Washington Publishing Company
Posted 1/8/2020