ED Coding and Reimbursement Alert

Question: We received an “unprocessable” claim from our Medicare Administrative Contractor (MAC). Can we appeal this?

Ohio Subscriber

Answer: No, you can’t appeal an unprocessable claim because, technically, it was never filed. Another term for” unprocessable” is “rejected.” Rejected claims never enter the adjudication process as denials do.

If a claim is deemed unprocessable, the reopening unit won’t be able to handle it. The CMS Internet-Only Manual describes an unprocessable claim as any claim with incomplete or missing required information, or any claim that contains complete and necessary information that proves invalid.

Remark code: If your remittance advice lists MA130 as the reason code, then you know that the claim is unprocessable — which means it wasn’t processed. That means you have no appeal rights because the claim wasn’t denied.

Do this: Your only option in this scenario is to correct the errors and resubmit the claim for processing.