The A/B MACs (A) 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 A/B MAC (A) includes what is available.
• If a submission is RTP for incomplete or invalid information, the A/B MAC (A) shall not report the submission on the MSN to the beneficiary.
The notice must only be given to the provider or supplier.
Refer to the implementation guide for the current ASC X12 837 institutional claim format for specifications. If a claim fails edits for any one of the content or size requirements, the A/B MAC (A) will RTP the submission to the provider of service.
NOTE: The data element requirements in the implementation guide may be superseded by subsequent CMS instructions. The CMS is continuously revising instructions to accommodate new data element requirements.
The A/B MACs (A) must provide a listing of the required data elements, including a brief explanation to providers and suppliers. A/B MACs (A) 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.