Tuesday, August 19, 2014

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.

Friday, August 8, 2014

What is Incomplete or Invalid Submissions


Services not submitted in accordance with CMS instructions include:

• Incomplete Submissions - Any submissions missing required information (e.g., no provider name).

• Invalid submissions - Any submissions that contains complete and required information; however, the information is illogical or incorrect (e.g., incorrect HIC#, invalid procedure codes) or does not conform to required claim formats.


The following definitions may be applied to determine whether submissions are incomplete or invalid:

• Required - Any data element that is needed in order to process the submission (e.g., Provider Name).

• Not Required - Any data element that is optional or is not needed in order to process the submission (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, then the primary insurer’s group name and number must be entered on a claim). If these conditions exist, the data element becomes required.


Submissions that are found to be incomplete or invalid are returned to the provider (RTP). The incomplete or invalid information is detected by the FI’s claims processing system. The electronic submission is returned to the provider of service electronically, with notation explaining the error(s). Assistance for making corrections is available in the on-line processing system (Direct Data Entry) or through the FI. In the limited cases where paper submission are applicable, paper submissions found to be incomplete or invalid prior to or during entry into the contractor’s claims processing system are returned to the provider of service by mail, with an attached form explaining the error(s).

The electronic records of claims that are RTP are held in a temporary storage location in the FI’s claims processing system. The records are held in this location for a period of time that may vary among FIs, typically 60 days or less. During this period, the provider may access the electronic record and correct it, enabling the submission to be processed by the FI. If the incomplete or invalid information is not corrected within the temporary storage period, the electronic record is purged by the FI. There is no subsequent audit trail or other record of the submission being received by Medicare. These submissions are never reflected on a RA. No permanent record is kept of the submissions because they are not considered claims under Medicare regulation

Monday, July 28, 2014

What is the time limit when DOS has different from and TO date

Determining Start Date of Timely Filing Period -- Date of Service

In general, the start date for determining the 12 month timely filing period is the date of service or “From” date on the claim. For institutional claims (Form CMS-1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim is used for determining the date of service for claims filing timeliness. Certain claims for services require the reporting of a line item date of service. For professional claims (Form CMS-1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item “From” date is used for determining the date of service for claims filing timeliness. (This includes DME supplies and rental items.) If a line item “From” date is not timely but the “To” date is timely, contractors must split the line item and deny the untimely services as not timely filed. Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed. What constitutes a claim is defined below.


Time Limitations for Filing Part A and Part B Claims

Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section §70.7 below for details of the exceptions to the 12 month timely filing limit.)

Appropriate Medicare Contractor

Submissions for services must be filed with the appropriate Medicare contractor. It is the provider’s or supplier’s responsibility to submit each claim to the appropriate contractor. Medicare contractors may attempt to re-route claims appropriately if they have enough information to do so. In the case of re-routed claims, services submitted for payment are not considered claims under Medicare regulations until received by the appropriate Medicare contractor.


Monday, July 14, 2014

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.

Wednesday, July 9, 2014

How to report multiple NDC code - and format

NDC Billing Instructions 

Molina EDI Help Desk reports that claims are being rejected because more than one NDC code is being billed on one service line.  Below you will find instructions on billing multiple NDC codes for the same drug on a claim.  

For  more  detailed  information  on  billing  NDC  codes,  please  see  the  BMS  website  at
www.dhhr.wv.gov/bms under the heading “HCPCS/Drug Codes”.  

NDC’s must be configured in what is referred to as a 542 format.  The first segment must include five digits, the second segment must include four digits, and the third segment must include 2 digits.  If an NDC is missing a number on the product label, the appropriate number of zeros must be added at the beginning of the segment.  Only the NDC as specified on the label of the product that is administered to the member is to be billed.  Every NDC must be billed with an N4 qualifier before the NDC with no hyphens or spaces, the unit qualifier such as F2 (International Unit), GR (Gram), ML (Milliliter), and UN (Unit) and the NDC quantity.  Billing instructions are available at www.dhhr.wv.gov/bms & Molina Medicaid Solutions at www.wvmmis.com. Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Multiple NDCs 

At times, it may be necessary for providers to report multiple NDCs for a single procedure code.  For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code NDC qualifier, NDC, NDC unit qualifier, and NDC units.  The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line.  The second line item with the
same procedure code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.

Prevnar Immunization 

Effective 12/30/2011 Prevnar 13® is available for WV Medicaid members over the age of 50. Prevnar 13® is FDA approved for adults 50+ years of age to help prevent pneumococcal pneu-monia, meningitis, and bacteremia caused by 13 strains of S pneumonia. CPT code 90670 is to be billed for adult vaccinations; the reimbursement includes the cost of administration – the im-munization administration codes are not to be billed separately for adult vaccines. Prevnar 13® is currently available for children up to the age of 6 through the Vaccines for Chil-dren (VFC) Program.  As with all VFC vaccines, bill the administration code with your charge for the service and the vaccine code with the SL modifier to indicate the vaccine was provided under
the VFC Program at no cost.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download