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Top Claim Submission Errors

Are you filing your Medicare claims and making the same mistakes with each submission? You can prevent and reduce the number of claim submission errors and denials that you are receiving. The Provider Outreach and Education team offers education to help reduce claim rejections and denials that are returned to providers. The information below will assist you and your billing staff with filing claims or making corrections to denied claims.

Returned Unprocessable Errors (RUC) are caused by incomplete or invalid information that is necessary to process the claim. The “Returned Unprocessable Claim” edits have been in effect since April 1996 and is still a top area of errors.

The edit process was developed by the Centers for Medicare and Medicaid Services (CMS) in an effort to reduce costs and administrative waste. This editing process returns paper and electronic claims to the provider as unprocessable. No appeal rights are afforded to these claims, or portion of these claims, because no “initial determination” can be made, therefore rendering the claim unprocessable. The billing staff should make corrections and must resubmit claims.  This listing is updated quarterly.

Quarter, YearErrorClaim Count
Claims Issue DetailsQ4, 2016

Procedure and Modifier Inconsistent

54379
Claims Issue DetailsQ4, 2016

Invalid Social Security Number or Health Insurance Claims (HIC) Number

40671
Claims Issue DetailsQ4, 2016

Missing/Incomplete/Invalid Charge

34735
Claims Issue DetailsQ4, 2016

Missing/Incomplete/Invalid Billing Provider/Supplier Primary Identifier

32975
Claims Issue DetailsQ4, 2016

Place of Service (POS)

25432
Claims Issue DetailsQ4, 2016

Clinical Lab Improvement Amendment (CLIA) Number

17576
Claims Issue DetailsQ4, 2016

Missing/Incomplete/Invalid Rendering Provider Information

16095
Claims Issue DetailsQ4, 2016

Missing/Incomplete/Invalid Group Practice Information

13722
Claims Issue DetailsQ4, 2016

Missing/Incomplete/Invalid Date(s) of Service

12342
Claims Issue DetailsQ4, 2016

Claim/Service not covered by this payer/contractor.

11895
Claims Submission Issues / ErrorsWe have printed the top RUC denials for claims received October 1, 2012 through December 31, 2012 in an effort to help educate the provider community. These denials totaled 297,848 claims returned as unprocessable.   The Reason Code, Remark and/or the Medicare Outpatient Adjudication (MOA) codes associated with the RUC denial identify each of these denials on the Provider Remittance Advice. These Reason Codes will alert you that the claim is a RUC denied claim.The following is a list of the top RUC denials received in the fourth (4th) quarter of 2012.1.      Referring provider primary identifier: The referring provider NPI is missing or invalid.  Ensure that the NPI for the referring physician is entered on the claim if applicable.  This will allow the claim to pass thru the pre-pass EDI edits instead of rejecting.  If the service or item was ordered or referred by a physician, enter the name of the referring or ordering physician in 17 and the NPI of the referring/ordering physician should be listed in item 17b of the Form CMS-1500 (8/05).

Claim Count:  54,831
Remark Code(s):
N285: Missing/incomplete/invalid referring provider name
N286: Missing/incomplete/invalid referring provider primary identifier  

2.      Invalid Social Security Number or Health Insurance Claims (HIC) Number: The patient’s health insurance claim number (Medicare Number) on the claim is not correct. Please contact the patient to verify that the number has not changed and that, and the suffix has not changed. After finding the correct number, correct the information in Item 1A or loop 2010BA and submit to Cahaba GBA as a new claim.

Claim Count:  41,171
Remark Code(s):
CO140Patient/ Insured Health Identification Number and Name do not match
MA61:  Missing/incomplete/invalid HICN
MA130: (MOA Code)

3.      Procedure and modifier inconsistent: 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 or the modifiers submitted on the line form an invalid or conflicting combination. Please see the modifier section for correct use of modifiers for Medicare.

Claim Count:  34,851
Remark Code(s):
CO 4: The procedure code is inconsistent with the modifier used or a required modifier is missing
MA130: (MOA Code)

4.      Clinical Lab Improvement Amendment (CLIA): Providers are submitting clinical labs with the following errors: omitting the CLIA certification number on the claim, transposing the CLIA number, typing the letter “O” for the number “0”, the CLIA certification number does not cover the laboratory service billed to Medicare or the certification has lapsed. In order to eliminate this denial, make sure that you include your CLIA certification number in block 23 of the CMS-1500 Claim Form or Loop 2300/2400 on EMC claims. Providers should make sure that your CLIA certification is current and includes all the laboratory services you provide in your office. If you need to upgrade your certification contact your local state agency at https://www.amconlabs.com/faq/CLIA_State_Agencies.pdf . The lists of clinical laboratory tests approved as waived can be viewed at https://www.cms.gov/CLIA/downloads/waivetbl.pdf . Providers can refer to the MLN brochure on CLIA to locate information on the different types of CLIA certificates at https://www.cms.gov/MLNProducts/downloads/CLIABrochure.pdf .

Claim Count:  28,937
Remark Code(s):
MA120: (MOA Code) Missing/incomplete/invalid CLIA certification number

5.      Group/Rendering provider information missing: Missing/incomplete/invalid group practice information. This error occurs when the claim is coded with the groups’ NPI in block 24J (2310B/2420A EMC) and 33A on 1500 claim form (2010AEMC) or the rendering physicians’ NPI is in 24J and 33A. If the rendering physician is part of a group, the rendering physician’s NPI should be in 24J and the groups’ NPI should be in 33A.

Claim Count:  28,883
Remark Code(s):
MA112: (MOA Code) Missing/incomplete/invalid group practice information
N256: Missing/incomplete/invalid billing provider/supplier name
N257: Missing/incomplete/invalid billing provider/supplier primary identifier
N258: Missing/incomplete/invalid billing provider/supplier address

6.      Rendering National Provider Identifier (NPI): Providers are submitting claims for their group/clinic without the rendering NPI on the claim. In order to eliminate this error, always include the Group NPI (Type 1 Organizational NPI) in Item 33a of the CMS-1500 Claim Form or Loop 2010AA on EMC claims along with your individual NPI (Type 2 Individual NPI) in item 24J or Loop 2310B/2420A, REF02 (1C) on EMC claims.

Claim Count:  27,250
Remark Code(s):
MA130: Your claim contains incomplete and/or invalid  information…the claim is unprocessable
N290: Missing/incomplete/invalid rendering provider primary identifier

7.      Place of Service (POS): This error is caused when the place of service billed on the claim is invalid or inconsistent with the procedure code billed.  Providers are billing with a place of service code that is not compatible to where the service is being rendered. In order to eliminate this error, providers should verify that they are reporting the POS code that applies to the setting in which the service was provided and that the submitted procedure code is compatible with that POS. For example, Office or Other Outpatient (procedure codes 99201-99215) should be billed with POS codes 11 (Office), POS 22 (Outpatient Hospital), etc., while home service (99341-99350) should be billed with POS 12 (Home). For a complete listing of place of service codes and definitions, refer to the CMS Internet Online Manual, Pub.100-04, Medicare Claims Processing, Chapter 26, Section 10 .

Claim Count:  25,240
Remark Code(s):
M77: Missing/incomplete/invalid place of service

8.      Invalid Charge:  The charge submission for the procedure code listed on the claims is missing, incomplete, and/or an invalid charge amount.  Common errors related to billing an invalid charge is the charge amount is missing from the claim(s), or an invalid/extra charge amount has been listed on the claim(s).  To avoid these types of errors complete all applicable information on the claim; additional remark codes are used to identify what information is missing or invalid. You must submit a new claim with the complete/correct information.  For a complete listing of Unprocessable claim, refer to the CMS Internet Online Manual, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r1750b3.pdf

Claim Count:  21,770
Remark Code(s):
M79:  Missing/incomplete/invalid charge

9.      Billing provider information: Providers are submitting claims with missing, incomplete or invalid billing information. This error occurs when provider is submitting claims with the incorrect NPI number in the billing provider field. Providers should verify that the correct type 1 NPI organizational number is being billed appropriately. There may be multiple facilities under the same tax identification number (TIN). For example, you may have a clinic/group organization and an Ambulatory Surgery Center (ASC) with the same TIN. There should be a separate organizational NPI for the clinic billing number and one for the ASC facility.

Claim Count:  18,845
Remark Code(s):
N257: Missing/incomplete/invalid billing provider/supplier primary identifier
N290: Missing/incomplete/invalid rendering provider primary identifier
N293: Missing/incomplete/invalid service facility primary identifier
N297: Missing/incomplete/invalid supervising provider primary identifier

10.  Invalid patient’s name: Missing/incomplete/invalid patient name which means that the patients name does not match what Medicare has on file. The name must be submitted exactly as it appears on the beneficiary’s Social Security Card. If the beneficiary has had a name change that does not reflect on the Social Security Card, the name still has to be submitted as on the card until an update has been made with Social Security.  Please include apostrophes, spaces and/or hyphens and Jr. / Sr. suffixes.   It is very important that you submit the patient’s complete name.

Claim Count:  17,949
Remark Code(s):
MA36: (MOA Code) Missing/incomplete/invalid patient name

Page last updated: February 19, 2013

 

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