Top Unprocessable Claims FAQs

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WPS Medicare publishes Frequently Asked Questions (FAQs) based upon the top unprocessable rejections we identify. The following FAQs are based upon the top reasons WPS Medicare rejected claims as unprocessable for the previous quarter.

  1. What are the top unprocessable denials for providers during the previous quarter?

    The following table lists the unprocessable denials our Medicare providers received during the previous quarter.

    Top Unprocessable Denials

    Second Quarter Fiscal Year (FY) 2012 (January, February, and March 2012)

    Description Occurrences Percentage of Total Claims
    RENDERING PHYSICIAN # INVALID/MISSING. SUBMIT A NEW CLAIM 68,394 .63%
    CLIA NUMBER INVALID OR MISSING 50,881 .34%
    MISSING OR INVALID MODIFIER 36,670 .34%
    THIS CODE IS NO LONGER VALID. RESUBMIT WITH THE CORRECT CODE 28,063 .26%
    FIELD 11 OF HCFA 1500 MUST BE COMPLETED 11,389 .11%

  2. What resources are available to indicate appropriate modifiers to use?

    WPS Medicare offers a Modifiers webpage. This page provides information on the correct use of numerous modifiers and allows you to verify that current modifiers are used. This page also provides the opportunity to stay up to date with any changes made to modifier descriptions by the American Medical Association (AMA) and/or the Centers for Medicare & Medicaid Services (CMS).

  3. I have been a Medicare provider for a long time. Why did my enrollment expire?

    Medicare deactivates a provider number when the provider has not submitted a claim for one year. If your provider number is deactivated, you will need to complete a new enrollment form and follow all of the guidelines for keeping your enrollment up to date.

  4. What does "PA, NP, OR CNS NOT INTERNALLY ASSOCIATED WITH BILLING PROVIDER" mean?

    The Medicare system does not have the Physician Assistant, Nurse Practitioner, or Certified Nurse Specialist associated to the group or practice billing for the service. Please contact provider enrollment to correct the issue.

  5. What fields are you looking for provider NPI numbers in?

    CMS Form 1500 or 5010 electronic equivalent requires them in:

    • Item 33A or 5010 electronic equivalent for the Billing Provider
    • Item 24J or 5010 electronic equivalent for the Performing Provider
    • Item 17B or 5010 electronic equivalent for the Ordering/Referring Provider

  6. What does "FIELD 11 OF HCFA MUST BE COMPLETED" indicate?

    Field 11 is where you indicate that the patient has primary insurance to Medicare.

    For paper claims: Indicate primary insurance information in Field 11 of the CMS-1500 or the word "None."

    For electronic claims: Indicate primary insurance information in appropriate loop or leave blank.

  7. Does Medicare allow a grace period when a procedure codes is no longer valid?

    Medicare does not allow for a grace period for invalid procedure codes. Providers must keep track of all changes and bill with the code in affect for that date of service.

  8. What number is missing when the reject is "CLIA NUMBER INVALID OR MISSING"?

    If you are billing electronically, check Loop Number 2400 and verify the Clinical Laboratory Improvements Act (CLIA) number is in the loop. If you have included the number, then contact our Electronic Data Interchange (EDI) department to see if the data is submitted correctly.

    If you are paper biller, check Item 23 on the CMS 1500 claim form to verify the number is correct.

    9. Page Last Updated: Thursday, 19-Apr-2012 14:56:18 CDT