Common sense steps for the prevention of claim denials

Article Outline

• Incorrect beneficiary identification
• Names must match exactly
• Check the Medicare card every time
• Ordering/referring physician identifier errors

Medicare claims often are denied as the result of common and easily preventable errors. Errors in provider or patient information are among the most common. Noridian Administrative Services, one of the nation's largest Medicare payment contractors, recently issued an advisory for health care practitioners who wish to avoid needless claim denials. The advice is applicable—and could prove valuable—to health care practitioners who file claims through virtually any Medicare Part B payment contractor in the nation.

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Incorrect beneficiary identification 

Noridian reports a substantial number of denied claims bear 1 of 2 commonly used Medicare Remittance Remark Codes: MA61—Patient cannot be identified as our insured or, MA36—Missing/incomplete/invalid patient name.

Both of these codes indicate that the patient identification listed in Medicare enrollment records does not match the information on the claim. That could mean the patient is not actually a Medicare enrollee. It could also mean the patient is enrolled in a Medicare plan (for example, a Medicare Advantage) other than the one to which the claim was filed. However, in many cases, the codes may simply mean that the patient was misidentified on the claim in some fashion.

Practitioners should carefully check patient eligibility and identification before filing claims as a way of preventing denials. When claims are denied for the above-mentioned reasons, practitioners should review the beneficiary information that was submitted, make any appropriate corrections, and resubmit the claim. That process might begin with checking the patient's Medicare eligibility. Medicare offers 2 easy ways to check a patient's eligibility status.

Both provide electronic access to:

Information on both the IVR and the PPTN can be found on Medicare payment contractor Web sites.

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Names must match exactly 

In many cases, the problem may be that the patient's name, or other identifying information for the patient, is listed incorrectly on the claim. Medicare regulations require patients be identified on claims exactly as they are listed in the Medicare records. Nothing may be changed, omitted, or added. If the name on the claim does not match the name in the Medicare records, the payment contractor may reject the claims as unprocessable. Any of the following common errors can prompt a Medicare payment contractor to deny a claim:

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Check the Medicare card every time 

Referring to a current copy of a beneficiary's Medicare card when filing a claim is the best way for providers to avoid such simple errors. Providers should keep a copy of the beneficiary's Medicare card on file for reference. The beneficiary's name and Medicare number should be submitted exactly as they appear on the Medicare card. Periodically, providers should ask their patients for their Medicare cards to verify the patient's information matches the information in the provider's files.

Providers that do not see the patient face to face should request a copy of the Medicare card from the ordering provider to ensure proper billing.

If a beneficiary indicates that the information on the Medicare card is incorrect or the information on the Medicare card is correct but the national file information is incorrect, providers should direct the beneficiary to contact the Social Security Administration at (800) 772-1213 to request a correction, but use the information on the card until a new card is issued.

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Ordering/referring physician identifier errors 

Medicare claims frequently are denied because of missing, incomplete, or invalid information for the ordering or referring physicians, according to Noridian. Claims that have been denied for this reason will be signified by 1 of 2 remark codes on the Standard Paper Remittance (SPR) or the Electronic Remittance Advice (ERA) that the provider receives.

Medicare requires information regarding the referring or ordering physician on several types of claims. Specifically:

In any of these cases, providers must provide the following information on the claim submission:

The CMS emphasizes that the NPI is now the only health care provider identification number accepted on Medicare claim forms. Medicare's Unique Provider Identifier Numbers (UPINs) are no longer accepted. The Administrative Simplification provisions of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a standard unique identifier for each health care provider. The NPI final rule, published in January 23, 2004, establishes the NPI as that standard identifier. The CMS began requiring NPIs on Medicare claim forms—both paper and electronic—on May 23, 2008. Medicare's UPIN Registry was discontinued on that date. If a UPIN is reported on a claim submission, the claim will be rejected, the CMS emphasizes.