Specialty specific unprocessable returned claims

Carriers must return the following claim as unprocessable to the provider of service/supplier:

a. For chiropractor claims:

1. If the x-ray date is not entered in item 19 for claims with dates of service prior to January 1, 2000. Entry of an x-ray date is not required for claims with dates of service on or after January 1, 2000.

2. If the initial date “actual” treatment occurred is not entered in item 14. (Remark code MA122 is used.)

b. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and the group’s name, address, and ZIP Code is not entered in item 33 or if the NPI is not entered in item 33a of the Form CMS-1500, if their personal NPI is not entered in item 24J of the Form CMS-1500. (Remark code MA112 is used.)

c. For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location where the order was accepted were not entered in item 32. (Remark code MA 114 is used.)

d. For physicians who maintain dialysis patients and receive a monthly capitation payment:

1. If the physician is a member of a professional corporation, similar group, or clinic, and the NPI is not entered in item 24J of the Form CMS-1500. (Remark code N290 is used.)

2. If the name, address, and ZIP Code of the facility other than the patient’s home or physician’s office involved with the patient’s maintenance of care and training is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered

e. For routine foot care claims, if the date the patient was last seen and the attending physician’s NPI is not present in item 19. (Remark code N324 or N253 is used.)

f. For immunosuppressive drug claims, if a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a or if the NPI is not entered in item 17b of the Form CMS-1500. (Remark code N264 or N286 is used.)

g. For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a or if the NPI is not entered in item 17b of the Form CMS-1500. (Remark code N264 or N286 is used.)