Basic of Handling of Invalid claim submission

 Handling Incomplete or Invalid Submissions 

 The following provides additional information detailing submissions that are considered incomplete or invalid.
The matrix in Chapter 25 specifies whether a data element is required, not required, or conditional. The status of these data elements will affect whether or not an incomplete or invalid submission (hardcopy or electronic) will be returned to provider (RTP). FIs should not deny claims and afford appeal rights for incomplete or invalid information as specified in this instruction.
The FIs should take the following actions upon receipt of incomplete or invalid submissions:

• If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a not required data element is accurately or inaccurately entered in the appropriate field, but the required data elements are entered accurately and appropriately, process the submission.

• If a conditional data element (a data element which is required when certain conditions exist) is not accurately entered in the appropriate field, RTP the submission to the provider of service.

• If a submission is RTP for incomplete or invalid information, at a minimum, notify the provider of service of the following information:
o Beneficiary’s Name; o Health Insurance Claim (HIC) Number; o Statement Covers Period (From-Through); o Patient Control Number (only if submitted); o Medical Record Number (only if submitted); and o Explanation of Errors.

NOTE: Some of the information listed above may in fact be the information missing from the submission. If this occurs, the FI includes what is available.

• If a submission is RTP for incomplete or invalid information, the FI shall not report the submission on the MSN to the beneficiary. The notice must only be given to the provider or supplier.