Q&A: Managing suspended claims

Q: How can I identify a suspended claim? Is there anything that can be done to move a suspended claim forward?

A: Claims that are suspended by Medicare can be identified in the Fiscal Intermediary Standard System (FISS) by a status code beginning with an “S.” Medicare will suspend claims for various reasons. Once a claim is submitted to Medicare, assuming that it has no errors and meets medical necessity requirements, it will remain in a suspended status until it is ready to be paid. Medicare may also suspend claims due to its own system issues that may prevent the claims from processing appropriately. Once the issues have been corrected, the claim will move to a different status.

Once a claim is suspended, there is little that the provider can do. Occasionally, a provider may need to provide the medical record to Medicare to move a claim out of the suspended status. In such a case, a medical record request will come from Medicare in the form of an Additional Development Request (ADR). Medicare must receive the requested medical records within 45 days of the request. Failure to submit the claim within that time frame will result in a denial.

Other reasons Medicare may suspend claims include the following:

• Eligibility information on the claim is being is being verified with the information on the Common Working File
• The claim may need manual intervention by the Medicare staff

For more information see The Contemporary Guide to Patient Financial Services.