- Introduction
- About Provider Outreach and Education
- ABN for Not Reasonable and Necessary Denials
- Appeals/Reopenings
- Assignment of Benefits
- Comprehensive Error Rate Testing
- CMS-1500 Claim Form
- Deceased Beneficiary Claims
- Electronic Data Interchange
- Evaluation and Management Services
- Fraud and Abuse
- Health Professional Shortage Area
- Hospice
- Limiting Charge
- Medical Policy Development
- Medigap
- Modifiers
- Nonphysician Practitioners
- National Provider Identifier
- Participation Program
- Payment Floor Standards
- Provider Enrollment
- Refunds and Overpayments
- Ordering and Referring Claims Information
- Return/Reject
- Standard Remittance ANSI Codes and Remittance Advice
- Appendix 1: Forms
- Appendix 2: Glossary
- Appendix 3: Place of Service Codes
Medicare Part B 101 Manual
Return/Reject
While it's easy to group processed claims as either approved or denied, there are differences in the way claims are returned unpaid by Medicare. Only claims that are filed with complete and correct information can be properly adjudicated for payment or denial.
Claims may be returned to the provider prior to entering the Medicare processing system. Paper claims may be screened for missing information and mailed back indicating why the claim is being returned. Electronic claims that fail initial edits will be returned via the acceptance report.
Claims that enter the Medicare processing system and are found to be incomplete or contain invalid information will be rejected via the remittance advice. New reject codes have been established to inform providers why the claim was rejected.
Claims that are complete and denied for medical necessity or improper billing will be denied via the remittance advice. These denials are indicated using the standard action codes.
In the past, claims that were denied for incomplete or invalid information surfaced inappropriately in the appeals process. On 4/1/1996, the return/reject (i.e., unprocessable claims) project was implemented. Under the return/reject process, both paper and electronic claims that contain incomplete or invalid information will be returned to the provider as unprocessable. No appeal rights are afforded because no initial determination can be made. The claim must be corrected and resubmitted as an initial claim.
Note: The appeals process is only available when a complete and correct claim has been submitted and Medicare has processed a payment or denial.
The table below provides further guidance for the action to take when certain reason codes appear on the provider remittance.
| Reason Code on Remittance | Provider Action |
|---|---|
| 31 = Claim denied as patient cannot be identified as our insured | Verify the Medicare number submitted on the claim matches the Medicare number on the patient’s Medicare card, to include the suffix.
|
| 109 = Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. | Check Item 32 on the claim filed for the state in which services were rendered. File the claim to the appropriate payer/contractor. In the case of a durable medical equipment, prosthetic, orthotic, or supply (DMEPOS) item, the beneficiary’s permanent home address determines to which durable medical equipment Medicare administrative contractors (DME MACs) the claim should be submitted. |
| B7 = This provider was not certified for this procedure/service on this date of service. | Check the Clinical Laboratory Improvement Amendments (CLIA) certificate number to make sure the laboratory service being billed is within the scope of the certificate type. |
| B11 = The claim/service has been transferred to the proper payer/processor for processing. Claim service not covered by this payer/processor. | Check with the carrier that the claim has been transferred to, for example Travelers, United Mine Workers Medicare or a health maintenance organization. |
| B15 = Payment adjusted because this service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. | The procedure code must be billed with a primary code. Check coding references for the primary and/or add-on code and resubmit the claim with both the primary and add-on code on the same claim. |
| MA130 = Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information. | Please submit a new claim with complete and correct information. Information is missing which is needed to process the claim. Check the claim to make sure all information is complete before submitting |
Revised 9/29/2023