Last Modified: 3/10/2019
Location: FL, PR, USVI
Business: Part A, Part B
Effective for claims processed on/after October 1, 2012, change request 7260 implemented a requirement for Medicare systems (FISS/MCS) to return claims when the beneficiary’s name does not match the Medicare ID on the common working file (CWF). These claims will be handled as follows:
• Part A claims will be returned to provider (RTP)
• Part B claims will be returned as unprocessable
If you receive a remit indicating the patient/insured health identification number and name do not match, you must advise the patient or his/her representative to contact their local Social Security office to have their files updated. Once the update has been made, you may submit a new claim for processing.
Note: Appeal rights are not afforded on claims that are returned to the provider or handled as unprocessable.
Source: CR 7260
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