Last Modified: 6/16/2022
Location: FL, PR, USVI
Business: Part B
Once a claim is processed, Medicare decides to either pay or deny. However, in some situations, a decision to pay or deny isn’t possible because the claim has billing errors. First Coast returns these unprocessable claims back for you to correct and submit.
The easiest way to find out why your claim was returned as unprocessable is to review your remittance advice. If you see alert code N211, your claim was returned to you for correction. The N211 alert code also states that the claim cannot be appealed. To identify the error on the claim, look for the MA130 remittance advice message with a corresponding reason code message to identify why the claim was incomplete or invalid.
MA27: Missing/incomplete/invalid entitlement number or name shown on the claim.
1. A procedure code is no longer valid for Medicare purposes for the date of service billed. First Coast sees an increase in this type of unprocessable claim during the first quarter of every calendar year as procedure codes may change.
• Resolution: Review the most current CPT manual to determine if a procedure code is still valid. If the procedure code is not valid, do not file your claims with that code. Find a more appropriate code. The CPT manuals are released in October of each year. Train your staff to review the coding manuals regularly.
2. Procedure codes related to quality measures are billed on a standalone claim without the main procedure code. This type of error is more frequent at the end of the year as providers try to meet the quality reporting requirements.
• Resolution: Ensure your quality measures are reported with the primary code. Waiting until the end of the year to submit your quality measures alone is not appropriate. It only increases your volume of unprocessable claims and reduces your income.
• guidelines require claims to be submitted and processed no later than 12 months from the date of service. Claims must be processed (paid or denied) by Medicare to be considered timely. Claims with missing, invalid, or incomplete information are returned to you as unprocessable and are NOT considered submitted. You must correct and resubmit for Medicare to process the claim.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.