CMS Pub. 100-04, ch. 1, § 70.2.3.2

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary’s Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

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 Medicare beneficiary identifier;

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NOTE: The data element requirements in the implementation guide may be superseded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.