Medicare Denial Codes

Medicare Denial CodesRemark 

Codes

Denial ExplanationAction
1Deductible Amount
2Coinsurance Amount
3Co-Payment Amount
4Procedure code is inconsistent with the modifier used or a required modifier is missing.

It means claim is denied when submitted with invalid or in-consistence modifiers with the procedure code or the required modifier missing.

Please check the modifier used for that particular procedure code, it may be invalid or inappropriate or missing.

Update the correct modifier and resubmit the claim as corrected claim

5The procedure code/bill type is inconsistent with the place of servicePlease check the place of service or procedure code used for that particular service.

Place of service may be incompatible with the procedure code billed.

Correct the Place of service or CPT code and resubmit the claim as corrected claim.

6The Procedure/revenue code is inconsistent with the patient’s age.

Procedure Code  billed is not valid for member’s age

Procedure code billed would be irrelevant to the patient’s age.

Update the correct CPT code and resubmit the claim as corrected claim.

7The Procedure/revenue code is inconsistent with the patient’s gender.

CPT code is not valid for patient’s gender

CPT Code billed would be irrelevant to the patient’s gender.

Update the correct CPT and resubmit the claim as corrected claim.

8The procedure code is inconsistent with the provider type/specialty(taxonomy)

.

Every provider has a number of taxonomy codes to choose from the types of service they perform, so we need to check the provider taxonomy codes to see if that provider is correctly set up for the type of service.

Need to set up the correct one.

Mismatch between the procedure code and the taxonomy billed. CPT billed may be irrelevant with taxonomy billed, need to check the CPT code.

Update the correct one and resubmit as corrected claim

9The Diagnosis is inconsistent with the patient’s ageDiagnosis code billed would be in-appropriate to the patient’s age.

Update the correct DX code and resubmit the claim as corrected claim.

10The Diagnosis is inconsistent with the patient’s genderDiagnosis Code billed would be in-appropriate to the patient’s gender.

Update the correct Diagnosis Code and resubmit the claim as corrected claim.

11The diagnosis is inconsistent with the procedure.

It Indicates invalid or Inconsistent or Incompatible between the Diagnosis and procedure Code submitted.

Check the medical records and see the diagnosis and procedure indicated.

Correct the claim with valid procedure or diagnosis code and resubmit the claim as corrected claim.

12The diagnosis is inconsistent with the provider typeMismatch between the Diagnosis code and the taxonomy billed. DX billed may be irrelevant with taxonomy billed, need to check the DX code.

Update the correct one and resubmit as corrected claim

13The date of death precedes the date of service.

Claim was submitted with a Postdates members death

Verify the DOS Billed

Correct the date of service and resubmit the claim as a new claim.

14The date of birth follows the date of service.
16M51Missing/Incomplete/invalid procedure code
16MA130Claim returned as un-processable
16N4Insufficient Primary EOB receivedFirst check the primary EOB submitted matches the claim submitted.

Resubmit the claim with complete primary EOB information.

16N51Electronic interchange agreement not on file for provider/submitter
16N64Claim returned as unprocessableThis item must be billed with spanned dates

Correct and resubmit as new claim

16N280Missing/Incomplete/Invalid pay-to provider identifier.Check the Box# 17 and 17B on HCFA form to verify referring physicians name and NPI number is updated and valid.

Correct and resubmit as new claim.

16N366Information required to make payment was missingCertificate of medical necessity is missing or contains invalid information on the claim submitted or Misc procedure was not submitted with appropriate information.

Verify the above information and resubmit as new claim.

17N366Lack of response to development letter
18N111Duplicate Claim/ServiceVerify if claim already processed.

If processed check to see is it paid or denied and work accordingly.

If claim denied as duplicate in error, call telephone reopening’s to reopen the claim.

19Claim denied because this is a work-related injury and thus the liability of the workers compensation carrier.Check the diagnosis on the claim matches the diagnosis on a worker compensation record.

If it is related to workers compensation, then submit the claim to Worker compensation carrier.

20Claim denied due to a Liability situationCheck the diagnosis on the claim matches the diagnosis on a liability record.

If it is related to Liability record, then submit the claim to Liability carrier.

21Claim denied due to payment by an auto medical/no-fault insurerCheck the diagnosis on the claim matches the diagnosis on the Auto medical/no-fault record.

If it is related to Auto accident, then submit the claim to auto medical/no-fault carrier.

22This care may be covered by another payer as per COBReview which insurance is primary for patient.

Check primary insurance paid or not.

If paid, resubmit the claim along with primary EOB.

If not submit the claim to primary insurance.

Note: To update COB information, patient has to call insurance company.

24Charges are Covered under a Capitation agreement/managed care plan.Verify eligibility to see which managed care plan is for the member.

Update the managed care insurance information and rebill claim to managed care insurance.

26Expenses incurred prior to CoverageCheck the eligibility to verify the policy effective date.
27Expenses incurred after coverage terminatedCheck the eligibility to verify the policy termed date.
29The claim was filed after the time limit.

Insurances Timely Filing Limit List

Verify the correct Date of service.

If DOS is correct then check the Claim received date.

If claim submitted within timely filing limit, call phone reopening’s to reopen the claim.

31Patient cannot be identified as our insuredCheck eligibility to verify correct information submitted.

Update and resubmit as a new claim

35N370Lifetime benefit maximum has been reached. The billing exceeds the rental months covered.Check to see how many rental months have been paid.

Also verify same equipment has not been provided by another provider for further action.

35M7Payment cannot be made after the reasonable purchase price has been met.
50These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.
50N115Medical Necessity denial based on Local Coverage Determination-LCD
51These are non-covered services because this is a pre-existing condition.
54Multiple provider/assistants are not covered
56Procedure/treatment has not been deemed ‘proven to be effective’ by the payer.
58Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
60M2This service is not covered since our records show that the beneficiary was in the hospital on the date of service billed.
96N103Non Covered Charges

Social Security records indicate that this patient was a prisoner when the service was rendered

96N108Upgrade information was invalid
96N115Item non covered based on LCD
96N372Medicare will pay for medically necessary maintenance and/or servicing as needed after the end of the 13th rental month
96M124No record of required base equipment on file for the item/accessory/replacement part that you are billing
96M6Servicing and repair are not billable with rented equipment, or maintenance and servicing is billed too soon
96M117,MA44Not Covered unless submitted via electronic claim. No appeal rights
97The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

The procedure code billed is inclusive with another procedure code already paid

In this case verify to which procedure code it is inclusive.

Then check with Coder’s for appropriate modifier can be added to distinguish from the procedure code.

107Supplies and/or accessories are not covered if the equipment is denied
109Claim is not covered by this payer or contractorCheck and see if claim denied is for Medicare advantage plan enrollment. If it is then submit the claim to the Medicare advantage plan.
109MA101Our records show that the beneficiary was in skilled nursing facility on the date of service billed.If patient is in a covered part A stay , item must be billed to SNF.

If not need to send redetermination.

110Billing date predates service date.Correct the date of service and resubmit as new claim.
119Benefit maximum for this time period or occurrence has been reached.
122Psychiatric reduction
125MA67Corrections to a previous claim
129MA130The Claim was submitted with conflicting MSP Claim adjustment reason codes
140Patient/Insured health identification number and name do not match.Verify eligibility to update the correct information (Medicare ID# and Name).

Update correct information and resubmit as new claim.

146Diagnosis was invalid for the date of service reportedUpdate the correct Diagnosis code and resubmit as corrected claim.
150N115Payer deems the Information does not support the level of service. This decision was based on LCDFirst verify does the document support the service billed.

Then check to see if the HCPCS code billed is medically necessary

Check with coder any specific modifier can be added.

If documentation supports the service billed, then submit to redetermination.

150M3Same or Similar equipment
151Documentation does not support the level of serviceFirst check to see does the documentation support the level of service billed.

Check LCD for maximum allowed.

Submit to redetermination along with documentation that supports the additional units of services.

151N362The number of Days or Units of Service exceeds our acceptable maximumCheck units billed within a date span.

If the number of units or date span was a billing error, then submit a reopening requires.

If everything correct submit to redetermination along with documentation.

172Requires certification/licensure specialty be on file with the national supplier clearinghouseVerify Licensure information on file with the NSC.

If Licensure information is incorrect, then update with the NSC.

Then resubmit any denied claims as new claims.

173M60No Certificate of medical necessity receivedCheck to see if CMN submitted along with claim.

If not resubmit the claim along with CMN.

176The prescription/certificate of medical necessity was not current or in effect for the date of service billed.Check to see if beneficiary previously had this equipment.

Then 13/15 months been billed and paid.

Check to see is there been a break in medical need?

Resubmit a new claim if documentation supports a break in medical documents.

If 13/15 months have not been billed and paid, resubmit as a new claim asking for extension of CMN.

176M60No recent/revision certificate of medical necessity received
179M6Maintenance and/or servicing of the item is not covered until 6 months after the end of the paid rental period
181Procedure code was invalid on the date of serviceCheck the procedure code submitted on the Date of service.

Correct and resubmit as corrected claim.

182Modifier that indicates was invalid on the date of serviceCheck the diagnosis code submitted on the Date of service.

Correct and resubmit as corrected claim.

182N56The modifier that indicates what rental month you are billing does not match what we have on file
185Rendering Provider is not eligible to perform/provide this service billedCheck to see if claim billed with correct NPI. If it is incorrect correct and resubmit as new claim.

If NPI is correct then verify whether PTAN has termed.

197Precertification/authorization/notification absentVerify authorization # is required for that particular service or not.

If required then verify authorization obtained or not.

If obtained call reopening to reopen the claim with authorization#.

198Precertification/authorization exceededVerify how many units approved under the authorization and whether authorization# used or not. If it is not exceeded call phone reopening’s to reopen the claim.
199Revenue code and Procedure code do not match
200Expenses incurred during lapse in coverage
201Beneficiary has worker’s compensation set aside fund
204This service/equipment/drug is not covered under the patient’s current benefit plan
204N171Payment for repair or replacement is not covered or has exceeded the purchase price.
251The attachment/other documentation that was received was incomplete or deficient
252An attachment/other documentation are required to adjudicate this claim/service.
253Sequestration – reduction in federal payment
276Services denied by the prior payers are not covered by this payer
287Referral Exceeded
288Referral absent
A1N370Claim/Service denied.
B7This provider was not eligible to be paid for this procedure.
B9These services denied as patient is in hospice.Check for Hospice care enrollment.

If not entitled for Hospice care then we need to contact local Social Security Office for corrections. Once data is corrected, need to resubmit as new claim.

B12Services not documented in patient’s medical records.
B15N70Date of Service is within a Home health episode
B15M80Payment is included in the allowance for another item or service provided at the same time.

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