Outpatient Facility Coding Alert - 2021 Issue 2
Reader Questions: Don’t Count on Appeals for Unprocessable Claims
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Article Overview
This reader Q&A addresses Medicare claim processing terminology and the difference between unprocessable and denied claims. It is relevant for billing and coding staff working with MAC remittance advice and CMS claim-processing guidance, especially when determining next steps after a rejection. The article covers the basic concepts behind rejected claims, the role of the CMS Internet-Only Manual, and the significance of a remittance advice remark code in identifying the processing status.
Why This Topic Matters
Understanding whether a claim was rejected or denied affects whether appeal rights exist and what corrective action should be taken. The article helps revenue cycle teams recognize when a claim must be corrected and resubmitted rather than appealed.
What You Will Learn
- How unprocessable claims are treated in Medicare claim processing
- Why rejected claims differ from denied claims
- How remittance advice can indicate a processing status issue
- What general next step is used when a claim cannot be processed
Who Should Read This
- Medical billers
- Coding professionals
- Revenue cycle staff
- Medicare claims staff
Codes Discussed
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