Returned or unprocessable claim – cms 1500
Please correct “returned” claims promptly because only when this is done will a provider have met his legal obligation for submitting a Medicare claim.
Definitions
Unprocessable Claim – 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.
Incomplete Information – Missing, required or conditional information on a claim (e.g., no National Provider Identifier (NPI)).
Invalid Information – Complete required or conditional information on a claim that is illogical or incorrect (e.g., incorrect NPI) or no longer in effect (e.g., an expired number).
Required – Any data element that is needed in order to process a claim (e.g., provider name, date of service).
Not Required – Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., patient’s marital status).
Conditional – Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, the insured’s name must be entered on the claim).
Please correct “returned” claims promptly because only when this is done will a provider have met his legal obligation for submitting a Medicare claim.
Definitions
Unprocessable Claim – 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.
Incomplete Information – Missing, required or conditional information on a claim (e.g., no National Provider Identifier (NPI)).
Invalid Information – Complete required or conditional information on a claim that is illogical or incorrect (e.g., incorrect NPI) or no longer in effect (e.g., an expired number).
Required – Any data element that is needed in order to process a claim (e.g., provider name, date of service).
Not Required – Any data element that is optional or is not needed by Medicare in order to process a claim (e.g., patient’s marital status).
Conditional – Any data element that must be completed if other conditions exist (e.g., if there is insurance primary to Medicare, the primary insurer’s group name and number must be entered on a claim or if the insured is different from the patient, the insured’s name must be entered on the claim).