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National Government Services, Inc.
 Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter
MMR-2007 10B, October 2007

Return to Provider and Auto Reject (by National Government Services Medicare System) Items of the Paper CMS-1500 (08/05) Claim Form

Effective July 1, 2007 the following ITEMS of the CMS-1500 (08/05) claim form will be either:

  1. Returned to Provider (RTP) - You will get the paper claim form returned to you in the mail.
  2. Auto Rejected (AR) by our Claims Processing System - You will get a Standard Paper Remittance (SPR) with your rejection.

ITEM #

REASON FOR RETURN

1a - Medicare Health Insurance Claim Number (HICN)

Medicare requires completion of this Item. If the Medicare Number field is blank or not in the correct format (9 numeric and 1 alpha character) the claim form will be returned to the provider (RTP).

5 - Patient’s Address

If any of the following fields are blank: (address, city, state, and zip code) the claim form will be automatically rejected (AR).

12 - Patient’s Signature

Medicare requires completion of this Item. If the patient’s signature and date, signature on file or abbreviation “SOF” and date are not present, the claim will be returned to the provider (RTP).

17a & 17b - Referring/Ordering Physician Number (Legacy UPIN/NPI)

If you are billing for a referring or ordering physician you need to complete ITEM 17, as well as 17a and 17b. The claim form will be returned to the provider (RTP) if the Legacy UPIN Number is in the NPI field or if the NPI number is in the Legacy UPIN field.

24A - Dates of Service

The FROM and TO dates should be consecutive and should equal the number of days or units in ITEM 24G. If the FROM and TO fields are blank, or if the “FROM” or the “TO” field is an invalid date or future date, the claim will be automatically rejected (AR).

24B - Place of Service

When the place of service is not 12 (home visit), then ITEM 32 must be completed or the claim form will be automatically rejected (AR).

24F and or 28 - Charges

Enter the charge for each listed line of service. If there is no charge in ITEM 24f (individual charge) or ITEM 28 (total charge) the claim form will be returned to the provider (RTP).

24J - Rendering Provider information for a group practice

If you are an INDIVIDUAL provider, LEAVE 24J BLANK. If you are an individual provider and you put your individual number in 24J, the claim form will be returned to the provider (RTP) since your PIN does not match the rendering physician number.

31 - Physician Signature and Date

The claim will be returned to the provider (RTP) if you do not have: provider’s signature and date, “signature on file” or abbreviation “SOF” and date and/or a computer generated signature.

32a & 32b - Service Facility Number (Legacy PIN/NPI)

Claim form will be returned to the provider (RTP) if the legacy PIN number is in the NPI field or if the NPI number is in the legacy PIN field.

33 - Physician’s number, name and address

If provider name, address, city, state, ZIP code, and the provider number (PIN or NPI) are not present, the claim form will be returned to the provider (RTP).

33a & 33b - Billing Provider Number (Legacy PIN/NPI)

Claim form will be returned to the provider (RTP) if the legacy PIN number is in the NPI Field or if the NPI number is in the legacy PIN number field.

Additional Items of a Paper Claim that Will Be Returned to Provider Effective 10/01/2007

Effective October 1, 2007 paper claims will be returned to providers that:

  1. Contain labels, or remnants of peeled labels, on any part of the claim form. Claims with labels or stickers prevent the ability for scanning and accurate claim processing.
  2. Contain writing in the top header margin of the claim form. All information needed to process a claim should be reported within one of the ITEMS of the claim form. Additional information should not be written or stamped in the top margin as this can prevent the ability for scanning and accurate claim processing.
  3. Contain multiple CMS-1500 claim forms (i.e., has more than one claim form and attachments or a continued claim). Each separate claim form must be submitted as a complete claim with a total dollar amount and no more than six lines of service. When multiple claim forms are submitted with one or more attachments, we are not able to determine which claim(s) go with which attachment(s).
  4. Preferred font is Arial, 10 or 11 point (no bolding, italics, or underlining).
  5. For computer-generated claims, laser jet printing is preferable. Do not use a dot matrix printer.
  6. Dark black border around edges of the claim form or ink smudges spanning across the claim form are not permitted. If there are dark black borders around the edges of the claim form, it is likely that you are not using the CMS-approved version of the CMS-1500 (08/05) claim form.

For complete instructions on the CMS-1500 (08/05) claim form please visit our Web site:
NJ - www.empiremedicare.com/partbNJ/1500/instructions0805/htm

NY - www.empiremedicare.com/partbNY/1500/instructions0805/htm