CMS Pub. 100-04, ch. 1, § 80.3.1

The following definitions apply to §80.3.2. For carriers the requirements apply to Part B

assigned and unassigned claims (Form CMS-1500) or electronic data interchange

equivalent.

Unprocessable Claim - Any claim with incomplete or missing, required information, or

any claim that contains complete and necessary information; however, the information

provided is invalid. Such information may either be required for all claims or required

conditionally.

Incomplete Information - Missing, required or conditional information on a claim (e.g.,

no Unique Physician Identification Number (UPIN) / Provider Identification Number

(PIN) or National Provider Identifier (NPI) when effective).

Invalid Information - Complete required or conditional information on a claim that is

illogical, or incorrect (e.g., incorrect UPIN/PIN or NPI when effective), or no longer in

effect (e.g., an expired number).

Required - Any data element that is needed in order to process a claim (e.g., Provider

Name, Date of Service).

Not Required - Any data element that is optional or is not needed by Medicare in order to

process a claim (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 or if the insured is different from the patient, then the

insured’s name must be entered on a claim).

Return as Unprocessable or Return to Provider (RTP)- Returning a claim as

unprocessable to the provider (RTP) does not mean that the carrier or FI should

physically return every claim it received with incomplete or invalid information. The

term “return to provider” is used to refer to the many processes utilized today for

notifying the provider or supplier of service that their claim cannot be processed, and that

it must be corrected or resubmitted. Some (not all) of the various techniques for

returning claims as unprocessable include:

• Incomplete or invalid information is detected at the front-end of the carrier or FI

claims processing system. The claim is returned to the provider (RTP’d) either

electronically or in a hardcopy/checklist type form explaining the error(s) and

how to correct the errors prior to resubmission. Claim data are not retained in the

system for these RTP'd claims. No RA is issued.

• Incomplete or invalid information is detected at the front-end of the claims

processing system and is suspended and developed. If requested corrections

and/or medical documentation are submitted within a 45-day period, the claim is

processed. Otherwise, the suspended portion is returned and the supplier or

provider of service is notified by means of the RA.

• Incomplete or invalid information is detected within the claims processing

system and is rejected through the remittance process. Suppliers or providers of

service are notified of any error(s) through the remittance notice and how to

correct prior to resubmission. A record of the claim is retained in the system

(NOTE: This applies to carriers only. FIs do not use the remittance advice

process for return to provider (RTP)).

A claim returned as unprocessable for incomplete or invalid information does not meet

the criteria to be considered as a claim, is not denied, and, as such, is not afforded appeal

rights.