Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05-18-12)

by  Find-A-Code™
Jul 9th, 2015

A “misdirected claim” is a claim that has been submitted to the wrong place. This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.

Each fee-for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing. Physicians and other suppliers are required to submit claims to the contractor having the appropriate jurisdiction. Jurisdictional rules are specified in this Chapter at Section 10.

A contractor may not knowingly adjudicate a misdirected claim and, as such, upon receipt of such a claim, must dispose of the claim in accordance with the specifications of this section or other relevant instructions.

This section addresses the following types of misdirected claims:

1. a CMS-1500 or electronic claim submitted to the wrong local contractor (Part B MAC or carrier);

2. a CMS-1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to a DME MAC;

3. a CMS-1500 or electronic claim submitted to a DME MAC that should have been submitted to a local contractor (Part B MAC or carrier);

4. a CMS-1500 or electronic claim submitted to a local contractor (Part B MAC or carrier) that should have been submitted to the Railroad Retirement Board (RRB);

5. a CMS-1500 or electronic claim submitted to a DME MAC or a local contractor (Part B MAC or carrier) that should have been submitted the United Mine Workers of America (UMWA);

6. a CMS-1500 claim that should be submitted to a DME MAC that is submitted to the wrong DME MAC, and

This subsection does not apply to:

1. misdirected beneficiary-submitted claims. See Section 80.3.2 of this Chapter regarding handling of such claims;

2. electronic claims for durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) that are submitted to the incorrect DME MAC (misdirected DMEPOS claims are automatically routed to the appropriate DME MAC jurisdiction for processing);

3. a claim submitted to the wrong Part A MAC or fiscal intermediary (FI), including a regional home health intermediary (RHHI).

Pub 100-04 Medicare Claims Processing Manual