Handling Incomplete or Invalid Submissions - Medicare claim tips

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. (See definitions in §70.2 above.) 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. (See §80.3.1 for Definitions.)

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.

The matrix in Chapter 25 specifies data elements that are required, not required, and conditional. These standard data elements are minimal requirements. A crosswalk is provided to relate CMS-1450 (UB-04) form locators used on paper submissions with loops and data elements on the ANSI X12N 837 I used for electronic submissions.
The matrix does not specify loop and data element content and size. Refer to the implementation guide for the current HIPAA standard version of the 837I for these specifications. If a claim fails edits for any one of these content or size requirements, the FI will RTP the submission to the provider of service.

NOTE: The data element requirements in the matrix may be superceded by subsequent CMS instructions. The CMS is continuously revising instructions to accommodate new data element requirements. The matrix will be updated as frequently as annually to reflect revisions to other sections of the manual.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers and suppliers. FIs must educate providers regarding the distinction between submissions which are not considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected and re-submitted.

Filing claim to Medicare after offset from Medicare advantage plan (HMO)

Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:
• prior enrollment of the beneficiary in an MA plan or PACE provider organization;
• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;
• the effective date of the disenrollment; and,
• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.
(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.
(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

How to File a Void Request on a Paper Claim

Requirements for Filing a Void Request

A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.

Voiding Claims on the Remittance Voucher

A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.

Voiding Claims on a Paper Claim Form


When requesting a void, the provider must:
·  Resubmit a photocopy of the original claim or a new claim form;
·  Enter the items listed on following page;
·  Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and

·  Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080

How to Resubmit a Denied Claim

Instructions
Check the remittance voucher before submitting a second request for payment.  Claims may be resubmitted for one of the following reasons only:

·  The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
·  The claim was denied due to incorrect or missing information or lack of a required attachment.

Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.


No Response Received

If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:

·  Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.

·  If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.

·  If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.

Correcting a Denied Claim

If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.

Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.

*  Did you wait thirty days after the original submittal before resubmitting a missing claim?

* If using a photocopy of a claim, did you make sure it was legible and properly aligned?

* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?

*  If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)

* Have you clipped all required attachments and documentation to the claim form?

*  Is the claim clean of all highlighting and whiteout?

*  Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?

Insurance Claims Processing cycel - different stage

Paper Claim Handling

When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.

Claim Entry 

Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.

Claim Adjudication 

FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.

Disposition of Claim

A claim disposition can be:

·  Paid: payment is approved in accordance with program criteria.

·  Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.

·  Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
 
Processing Time Frames

Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.

Basic rules for submitting clean claim - Medicaid

Basic Rules for Completing Blank Non-Institutional 081 Claim Forms

There are some basic rules to follow before completing the claim form.

·  Make sure the Non-Institutional 081 is the right form to use for the claim.
·  Enter all information using black type or a pen using black ink. (The fiscal agent can only process clean claims with black type or ink. Use only black ink on adjusted claims to indicate the item being corrected.)
·  Be sure the information on the form is legible.
·  Enter information within the allotted spaces.
·  Do not use whiteout.
·  Complete the form using the service-specific Coverage and Limitations Handbook as a reference

Before Completing the Form
Before filling out a claim form, answer the following questions:
·  Was the recipient eligible for Medicaid on the date of service?
·  Has the recipient’s eligibility been verified?
·  Was a MediPass or HMO authorization obtained, if applicable?
·  Was the service or item covered by Medicaid?
·  Was the service in the recipient’s plan of care?
·  Was the case manager’s authorization obtained, if applicable?
·  Has a claim been filed, and a response received, for all other insurance held by the recipient?

If all of the above information is not available, review the instructions in this handbook.

If the response to all of the above questions is “yes,” fill out the claim form following the step-by-step instructions for each item on the form.

Recipient’s Name 

Enter the recipient’s last name, first name, and middle initial exactly as it appears on the gold, plastic Medicaid identification (ID) card or other proof of eligibility

Medicaid Identification Number

Enter the recipient’s ten-digit Medicaid ID number. Do not enter the number on the Medicaid ID card. This is a card control number, not the recipient’s Medicaid ID number.

How to submit complete or clean claims

 For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a
member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at
the time of service.

To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims
processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.
Pricing and payment calculations are not included.

Allow enough time for your claims to process before sending second submissions or tracers, then check their status online at UnitedHealthcareOnline.com. If you do need to submit second submissions or tracers, be sure to submit them
electronically no sooner than forty-five (45) days after original submission.
Complete claims include the information listed under the Complete Claims Requirements section of this Guide.

We may require additional information for particular types of services, or based on particular circumstances or state requirements. If you have questions about submitting claims to us, please contact Customer Care at the phone number listed on the member’s health care ID card.


Complete claims requirements

•     Member’s name
•     Member’s address
•     Member’s gender
•     Member’s date of birth (dd/mm/yyyy)
•     Member’s relationship to subscriber
•     Subscriber’s name (enter exactly as it appears on the member’s health care ID card)

•     Subscriber’s ID number

•     Subscriber’s employer group name

•     Subscriber’s employer group number

•     Rendering Physician, Health Care Professional, or Facility Name

•     Rendering Physician, Health Care Professional, or Facility Representative’s Signature

•     Address where service was rendered

•     Physician, Health Care Professional, or Facility “remit to” address

•     Phone number of Physician, Health Care Professional, or Facility performing the service (provide this information
in a manner consistent with how that information is presented in your agreement with us)

•     Physician’s, Health Care Professional’s, or Facility’s National Provider Identifier (NPI) and federal Tax Identification Number (TIN)

•     Referring physician’s name and TIN (if applicable)

•     Date of service(s)

•     Place of service(s) (for more information see: cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pdf)
•     Number of services (day/units) rendered

•     Current CPT-4 and HCPCS procedure codes, with modifiers where appropriate

•     Current ICD-9-CM (or its successor) diagnostic codes by specific service code to the highest level of specificity (it is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is
related to a line item)
•     Charges per service and total charges

•     Detailed information about other insurance coverage

•     Information regarding job-related, auto or accident information, if available

•     Retail purchase cost or a cumulative retail rental cost for DME greater than $1,000

•     Current NDC (National Drug Code) 11-digit number for all claims submitted with drug codes. The NDC number must be entered in the 24D field of the CMS-1500 Form or the LIN03 segment of the HIPAA 837 Professional
electronic form.

Sumitting claim for payment by patient

To File a Medicare Claim Yourself

You will need to print out and complete the form called Patient’s Request for Medical Payment, Form CMS 1490S. The form is available for download on cms.hhs.gov in the CMS Forms section. Once there, you will need to do three things: (1) print out the 1490S form; (2) select and print out the applicable instructions; and (3) review all of the information on this page about how to file a claim form.



If you want Medicare to give your personal health information to someone other than you, you need to let Medicare know in writing. You can fill out the "1-800 Medicare Authorization to Disclose Personal Health Information" form. Call 1-800-MEDICARE (1-800-633-4227) to get a copy of the form, or you can download the form in the Medicare Online Forms section of this website.

You should take the following steps if your Doctor or Supplier does not file the Medicare claim in a timely manner:

• Step 1 - Contact Your Physician or Supplier: Call your physician or supplier directly and ask the physician or supplier to file a Medicare claim.
• Step 2 - Contact 1-800-Medicare: If your physician or supplier still does not file a Medicare claim after you have called and asked, you should call 1-800-Medicare (1-800-633-4227). Also ask 1-800-Medicare for the exact time limit for filing a Medicare claim for the service or supply that you received.

IMPORTANT: There is a time limit for filing a Medicare claim. If a claim is not filed within this time limit, Medicare cannot pay you its share. The time limit may be as short as 15 months or as long as 27 months depending on when you received the service or supply. It is important that you ask 1-800-Medicare what the time limit is for filing your claim.

• Step 3 - When You Should File a Claim: You should only need to file a Medicare claim in very rare situations. You should only file a Medicare claim yourself when:

• you have completed steps 1 and 2 above; AND
• the physician or supplier still has not filed the Medicare claim; AND
• it is close to the time limit for filing your Medicare claim. (For example, if your time limit is 15 months, you should consider filing a Medicare claim if the physician or supplier has not filed the Medicare claim 12 months after you received the service or supply). 

How to File a Claim

Medicare claims must be filed within one full calendar year following the year in which the services were provided. For example, if you see your physician on March 22, 2009, the Medicare claim for that visit must be filed by December 31, 2010.


Is your Pharmacy or Supplier enrolled in Medicare?

If the answer is no, you will be responsible for the entire bill for any drugs or supplies purchased. Important information you need to know before you make your purchase.


Note: This information on filing a Medicare claim only applies if you are in the Original Medicare Plan. If you get your Medicare healthcare through a Managed Care Plan or a Private Fee-for-Service Plan, Medicare claims are not filed. Medicare pays these private insurance companies a set amount every month. Therefore, they do not need to file Medicare claims.

My Provider or Supplier Accepts Medicare Assignment


You pay your share of the bill (coinsurance and deductibles) to the provider or supplier. The provider or supplier files a Medicare claim. Medicare pays its share of the bill directly to the provider or supplier.



My Physician or Supplier Does Not Accept Medicare Assignment

Note: Only physicians and suppliers can decide not to accept assignment.

If your physician or supplier does not accept assignment for covered services, your physician or supplier may require that you pay most or all of the bill at the time you receive services or supplies. However, the physician or supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you. Medicare cannot pay you its share of the bill until a Medicare claim is filed

different types of filing

A patient is registered in the system with his/her coverage details and then that patient's treatments are entered and updated in the system. These claims need to be sent to the patient's primary insurance.

This process of sending the charges to the patient's Insurance Company is called Filing Claims.

A service performed by the physician and entered in the system is called Charge but when the same charge is filed to that patient's Insurance Company, it is called Claim.

Claims may be sent in two ways:

Paper claims

Electronic claims.

Electronic claims are sent in ANSI/NSF Format. Paper claims are sent in CMS Forms-1500

two types of format

ANSI- American National Standards Institute (ANSI) - A national voluntary organization of firms and private individuals who develop industry standards used in a wide variety of business applications.

National Standard Format (NSF) - Also known as “flat file” format.

It is one of the two standardized electronic formats that are currently accepted by Medicare.