What is rejected or unprocessable claim?

Return as Unprocessable or Return to Provider (RTP) – Returning a claim as unprocessable to the provider does not mean that the contractor will physically return every claim it receives with incomplete or invalid information. The term “Return To Provider (RTP)” is used to refer to the many processes utilized today for notifying the provider or supplier of service that their claim cannot be processed and that it must be corrected or resubmitted. Some (not all) of the various techniques for returning claims as unprocessable include:
*  Incomplete or invalid information is detected at the front-end of the contractor claims processing system. The claim is returned to the provider either electronically or in a hardcopy/checklist-type form explaining the error(s) and how to correct the errors prior to resubmission. Claim data is not retained in the system for these RTP claims. No Remittance Advice (RA) is issued.

* Incomplete or invalid information is detected at the front-end of the claims processing system and is suspended and developed. If requested corrections and/or medical documentation is submitted within a 45-day period, the claim is processed. Otherwise, the suspended portion is returned and the supplier or provider of service is notified by means of the RA.

* Incomplete or invalid information is detected within the claims processing system and is rejected through the remittance process. Through the RA, suppliers or providers of service are notified of any error(s) how to correct prior to resubmission. A record of the claim is retained in the system. (Note: This applies to contractors only. FIs do not use the RA process for RTPs.)

A claim returned as unprocessable for incomplete or invalid information does not meet the criteria to be considered as a claim, is not denied and, as such, is not afforded appeal rights.

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