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.