Last Modified: 11/19/2018 Location: FL, PR, USVI Business: Part B
What you should do with claims returned as unprocessable
First Coast Service Options, Inc. (First Coast) is experiencing a large volume of appeals filed on claims that were returned as unprocessable. Claims that are considered returned as unprocessable are not appealable.
Do not file an appeal
• When you file an appeal on an unprocessable claim, First Coast will return the correspondence to you with a letter instructing the provider to refile a new claim. Response letters are typically generated within 60 calendar days after your appeal request was submitted.
• Filing an appeal on an unprocessable claim only delays payment and could result in a timely-filing denial if not re-filed with the correct information within the timely-filing period.
How to handle a claim returned as unprocessable
• Claims returned as unprocessable will include the MA130 remittance advice message with a corresponding reason code message to denote why the claim was incomplete or invalid.
• Review these frequently-asked questions to determine why First Coast was not able to process the claim.
• Resubmit a corrected claim.
The Medicare guidelines for unprocessable claims can be found in the Medicare Claims Processing Manual (100-04), Chapter 1, Section 80.3. See https:/www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf .
The Medicare guidelines for completion of form CMS-1500 can be found in the Medicare Claims Processing Manual (100-04), Chapter 26, Section 10. See https:/www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf .
Communication letters to top providers that file appeals on unprocessable claims
First Coast will be sending communication letters to providers in the future who submit appeals on unprocessable claims. These letters will provide details on the number of appeals requests received on unprocessable claims by the applicable providers.
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.