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Test Your Medicare Smarts With Claims Q&A

Test Your Medicare Smarts With Claims Q&A

Avoid claim errors and denials by following these pro tips from industry experts.

Ensuring that Medicare claims are correct and complete can be a challenging job. Even the slightest mistake can make a claim unprocessable, creating hassles galore for the person investigating the problem. We’ve put together a tough question and answer set on five of the most common claims issues that plague practices. Read on for detailed advice from the experts.

Know This CMS-1500 Rule

Question 1: Is it OK to scribble on a CMS-1500 claim form?

Answer 1: No. “Never write on a CMS-1500 form,” cautions Carolyn Henson with National Government Services (NGS) Medicare in the Aug. 25 webinar “Reducing Unprocessable Claim Rejections.” Unfortunately, the Part B Medicare Administrative Contractor (MAC) sees that a lot, Henson says.

The Centers for Medicare & Medicaid Services (CMS) explicitly outlines the do’s and don’ts for the CMS-1500 in Chapter 26, Section 30 of the Medicare Claims Processing Manual. In fact, warns Part B MAC WPS Government Health Administrators’ online guidance, “claims that do not meet the CMS-1500 form specification requirements may be rejected and returned as unprocessable denials.”

Tip: Whether you’re typing a paper version of CMS-1500 or plugging data into the electronic form, do not insert special characters such as hyphens, parentheses, dittos, or dollar signs, NGS says. Bolding, underlining, and italicizing are also forbidden. You should also stick with one font type throughout; Times New Roman is preferred, according to WPS.

Verify Beneficiary’s Eligibility With Data Requirements

Question 2: How many required elements do MACs want to verify a Medicare beneficiary’s eligibility on an electronic claim form?

Answer 2: To verify your patient’s eligibility, NGS says you must include four data elements: the beneficiary’s first name or initial, last name, Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN), and birth date.

Consider Signature Logs

Question 3: What can a practice do if a physician’s signature is illegible?

Answer 3: You can send a signature log or attestation statement to support the identity of an illegible signature, according to NGS’ Lori Langevin in a recent webinar on signature requirements.

“A signature log is a typed listing of the provider or providers identifying their name with a corresponding handwritten signature,” relates NGS’ Gail O’Leary. You must also include the credentials associated with the initials or the illegible signature.

You may include the signature log on the same page where the initial or illegible signature is located or in a separate document, O’Leary says. Just make sure that the signature log is a part of the patient’s medical record.

You can also submit an attestation statement if the provider’s signature is illegible. For Medicare to consider an attestation statement valid, the author of the medical record entry must sign and date the statement, O’Leary explains. The statement must also include the appropriate patient information.

Understand the Basics of Unprocessable Claims

Question 4: Is it a good idea to appeal an unprocessable claim?

Answer 4: No. Not only is it not a good idea; it’s not possible.

If a claim is deemed unprocessable, the reopening unit won’t be able to handle it. “The CMS Internet-only Manual describes an unprocessable claim as any claim with incomplete or missing required information or any claim that contains complete and necessary information; however, the information provided is invalid,” O’Leary says. “Such information may either be required for all claims or required conditionally.”

If your remittance advice lists MA130 as the reason code, the claim is unprocessable and a new claim needs to be submitted with correct and complete information.

If your claim is rejected, “there are no appeal rights on this type of denial because your claim was never actually processed, so there is nothing to appeal,” O’Leary explains. “Your only option is to correct your errors and resubmit the claim for processing.”

Check All Provider Specifics Before Submission

Question 5: What is one of the top reasons claims are registered as “unprocessable?”

Answer 5: According to NGS, 29 percent of the Part B MAC’s claims were rejected due to provider data errors. Some of the top reasons include:

  • Incorrect National Provider Identifiers (NPIs)
  • Nicknames for the various providers instead of actual names
  • Wrong organization listed
  • Dates that don’t match the medical record
  • Incorrect place of service (POS)

Tip: Before you submit a claim, review the documentation, and identify the specifics on the referring, ordering, rendering, or attending physician. This includes cross referencing the providers’ information with the medical record and what’s in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).

You may also want to log in to one of CMS’ many resource sites, NGS advises. These include:

  • Data sets: For Medicare’s ordering and referring data files, data sets offer a wealth of information on providers that can help you pinpoint claims data. Find out more at
  • NPPES: If you need to make a query or differentiate NPI data, the National Plan and Provider Enumeration System (NPPES) is your best bet. NPPES “assigns NPIs, maintains and updates information about healthcare providers with NPIs, and disseminates the NPI Registry and NPPES Downloadable File,” says CMS. Log in to NPPES at https://nppes.cms.hhs.gov/#/.
  • POS code set: Your billing team may need to revisit Medicare’s POS code set for professional claims, NGS suggests. Check out CMS guidance on POS codes at www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.

Lastly, you may want to look at your MAC’s guidance on filling out both the paper and electronic versions of the CMS-1500. Each jurisdiction has helpful tools and interactive systems to guide you through the process.

Kristin Webb-Hollering
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About Has 6 Posts

Kristin J. Webb-Hollering is the editor-in-chief of TCI compliance newsletters Part B Insider, Medicare Compliance and Reimbursement, and Health Information Compliance Alert.

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