Matching Claims Data to Beneficiary Records

Revision to the Centers for Medicare & Medicaid Services (CMS) prior directive: On April 22, 2005 claims that fail the matching edits will not be denied, but will be determined unprocessable and returned to the provider.

In October 2004, CMS made a software change to require an exact match on beneficiary First Initial, Surname, and Health Insurance Claim Number submitted on the claim. Since this change was implemented the number of unprocessable claims because of name/number mismatch tripled. To resolve these unprocessed claims, providers should bill using the name and number as it appears on the beneficiary Medicare card.

Published by XIFIN

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