Updated: March 27, 2013
- I need to find out if a beneficiary has had a specific item
in the past (same or similar inquiry). What's the best way to find
Information on same and similar equipment regarding capped rental items and inexpensive or routinely purchased (IRP) items is available through the IVR, at 1.866.238.9650. To access this information on the IVR, choose option 2 for "Beneficiary Information" and then either option 2 for "CMN Status" or option 3 for “Oxygen CMN Status.” You will need the following information to utilize the IVR:
- Last five digits of your Tax Identification Number (TIN)
- First initial of the beneficiary's name (including prefixes)
- First six letters of the beneficiary's last name (including suffixes and hyphenated last names)
- Date of birth
- HCPCS code of the item you are inquiring about
The IVR will report the following information if there is same or similar equipment on file:
- Whether or not a CMN/DIF is on file, including the HCPCS code
- CMN/DIF initial date, revised date, and/or recertification date
- Length of need
- Number of months paid (if rented)
- Last paid date (if rented)
- Phone number of previous supplier (if rented)
Note: CSRs are unable to release any extra information outside of what the IVR can provide.
You are required to utilize the IVR for same and similar inquires unless you are inquiring on a same or similar item that does not require the DME MAC to set up a CMN/DIF (for example, CPAP supplies, as well as other items that are not capped rental or IRP items). Contact Customer Service at 1.866.270.4909 in this situation.
For more information about the IVR and its abilities, please refer to the IVR Script and Flow Chart.
- My claims are denying CO-150, remark code M3 – "Payer
deems the information submitted does not support this level of service.
Equipment is the same or similar to equipment already being used." What
should I do?
The first thing to look for is whether or not the beneficiary has or has had equipment that is same or similar to the equipment you are billing and whether or not that equipment has met the reasonable useful lifetime (five years for most DME). These denials typically must be appealed through redeterminations. You may also choose to pick up your equipment rather than pursue payment.
If the reasonable useful lifetime has not been met and the beneficiary still has the previous equipment, payment cannot be made.
If the reasonable useful lifetime has not been met and the previous equipment was picked up by the original supplier, and there was a break in medical need greater than or equal to 60 days plus the days remaining in the last rental month, then you should file an appeal through redeterminations with documentation that supports the break in medical need.
If the reasonable useful lifetime has not been met and the previous equipment was lost, stolen, or irrevocably damaged, then you should appeal through redeterminations with appropriate documentation (such as a police report).
- What would the next step be for a claim that denied because
the beneficiary was in a Skilled Nursing Facility (SNF)?
If the beneficiary is enrolled in a covered Part A Stay, the SNF and not the supplier would bill Part A. As a result, you would look to the SNF for payment rather than the beneficiary or the DME MAC. For more information regarding Skilled Nursing Facilities, including a link to the Consolidated Billing List, as well as a list of the items which are billable when the beneficiary is in a non-covered Part A stay, please see the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
Also, SNF/inpatient hospital stay information is available on the DME MAC Jurisdiction C IVR. The SNF/inpatient hospital stay option provides:
- Whether or not a beneficiary has a SNF or inpatient hospital facility claim on file for the date of service entered
- NPI of the facility if the beneficiary is still a patient
- Type of discharge
- Discharge date
To access the SNF/inpatient hospital stay option on the IVR, press option 2 for "Beneficiary Information" from the main menu, and then press 1 for "Beneficiary Information". The IVR will provide eligibility dates, deductible, and other insurance information and then will prompt you to select 1 for "SNF/Inpatient Hospital Stay."
- How can I determine if a beneficiary is enrolled in a Medicare
Advantage Plan (MAP)?
MAP data can be retrieved through the IVR by calling 1.866.238.9650. To access the MAP information on the IVR, press option 2 (Beneficiary Information) from the main menu, then option 1 (Beneficiary Eligibility). After following the prompts, the IVR will report the effective dates of the MAP enrollment, the name of the MAP (if available), and the contract ID (usually one letter and four numbers). A list of names, addresses, and phone numbers for MAP contractors can be found on the CMS website.
- I am receiving a CO-176 denial (payment is denied because
prescription is not current). Why?
This type of denial is generally a result of billing outside of the end date on a CMN/DIF, which could be 13 or 15 months (the end of the capped rental period). The following is an example of this situation:
A beneficiary has a K0001 on file with an initial date of January 1, 2008. The 13th month of rental would normally be billed for January 1, 2009; however, one month during the rental period denied because the beneficiary was in a Skilled Nursing Facility (SNF). As payment will not be made for the month the beneficiary was in the SNF, the 13th month for the capped rental period would have to come in February 2009. The claim for February would deny as CO-176 unless there is a claim narrative asking to extend the rental period for the remainder of the rental months.
The narrative request to extend the rental period would also be needed if the item was originally provided by another supplier and there is no justification to start a new capped rental period. If the item was originally provided by another supplier and you believe a new capped rental is warranted, resubmit the claim with a narrative documenting why a new capped rental should begin.
- When billing a claim for an oxygen rental, I
am getting a CO-35 or CO-A1 denial with remark code N370 – "Lifetime
benefit maximum has been reached. Billing exceeds the rental months
covered/approved by the payer." Why?
Beginning January 1, 2006, oxygen equipment rentals will cap after 36 months have been paid. For beneficiaries who received the equipment prior to 2006, the 36-month total will begin to accumulate beginning with the first claim on or after 1/1/2006.
If you believe you received this denial in error and that not all 36 rental months have been paid, call our Customer Service line at 1.866.270.4909 to have a Customer Service Representative research the issue. In cases where you have received this denial when billing for replacement oxygen at the beneficiary's discretion due to the reasonable useful lifetime being met, it is possible one or more required elements were missing to process your claim correctly. For replacement oxygen, the following elements should be on your first month's claim:
- RA modifier (for dates of service on or after 01/01/09) or RP modifier (for dates of service prior to 01/01/09)
- Narrative explaining why the equipment was being replaced, as well as the date the beneficiary received the equipment being replaced (previous initial date)
- New initial CMN stating the most recent qualifying oxygen testing (new testing is not required, unless there was a break/change in medical need which lasted more than 60 consecutive days plus the remaining days in the last previous rental month)
For more information regarding oxygen and oxygen equipment please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 5.
- I called the IVR to check claim status and it says there is
nothing on file for the date that I entered or that the claim that
I submitted is not there. I haven't received anything telling me my
electronic claim was rejected. What do I do?
First, make sure the supplier information (NPI, PTAN, TIN) you are using is the same on the claim that you are checking status on. The IVR will only give claim status for the NPI/PTAN/TIN you entered at the start of the call. If this is not the issue, try resubmitting the claim. If your sources are saying the claim transmitted correctly, but the IVR still is not showing the claim on file, contact the Common Electronic Data Interchange (CEDI) at 1.866.311.9184. If you are receiving a rejection report regarding claim content, contact our Customer Service Line at 1.866.270.4909.
- How do I fix a claim that denied CO-176 with
remark code M60 – "Payment
denied because the prescription is not current," when billing a
claim for oxygen equipment?
This denial is usually due to a missing recertification CMN on file. For group one oxygen patients, a recert CMN is due 12 months after the initial date. For group 2 oxygen patients, a recert CMN is due three months after the initial date. If there is previous oxygen equipment on file, and there was a break in service due to a change in medical need greater than 60 days plus the days remaining in the last rental month, then resubmit your claim with your initial CMN and include the break in service information in the claim narrative. Otherwise, a recert CMN will be needed in order to continue payment for oxygen.
- What are my possible next steps with a medical necessity denial
(CO-50, remark code N115) based on a Local Coverage Determination (LCD)?
Try following these suggestions:
- Check the LCD and/or related Policy Article for the equipment you are billing. If a CMN/DIF is required and not submitted with the claim, send a written request to Reopenings along with the appropriate CMN/DIF.
- If a required CMN/DIF was submitted and you believe the claim should not have denied, submit a redetermination request with any additional documentation to support medical necessity.
- Check to see if the item you are billing is diagnosis driven (meaning the item requires a specific ICD-9 diagnosis code in order to establish medical necessity). If the wrong diagnosis code was billed by mistake, submit a request to reopenings to correct the error.
- Check to see if a development (ADS) letter was received. If a development letter was received and not responded to, submit the requested documentation from the ADS letter to redeterminations.
- Request a reopening for any clerical error/minor omission.
If the item requires a KX modifier per the LCD, you will need to file an appeal through Redeterminations in order to add, change, or remove the KX modifier. The same rule applies to the GA, GZ, and GY modifiers. For additional information regarding these modifiers, please refer to the Archived News Section of our website for the July 30, 2009 article entitled: IMPORTANT CHANGE - KX, GA, GZ and GY Modifiers - Claim Rejection as well as an October 29, 2009 and December 2, 2009 article entitled: Reopening Requests for Modifiers KX, GA, GZ and GY.
Note: You cannot resubmit a medical necessity denial. It must either be adjusted through Reopenings (if a clerical error or minor omission) or appealed through Redeterminations.
- Explain how we should approach billing for a
beneficiary that regularly moves from one state to another (a "snowbird")
or has recently moved to another jurisdiction.
Claims should be submitted to the jurisdiction in which the beneficiary resides at the time of the claim's submission regardless of where they lived on the date of service. For example: From 11/1/08 through 4/31/09 a beneficiary resided in Jurisdiction C and received a walker on date of service 1/1/09. Beginning 5/1/09 to current, the beneficiary is residing in Jurisdiction A. If the suppler submits their claim prior to 5/1/09, then the claim should be filed to Jurisdiction C. If the supplier waits to submit their claim until after 5/1/09, then the claim should be filled to Jurisdiction A, despite the fact they were in Jurisdiction C when they received the walker.
If you believe you received a CO-109 denial ("Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor") in error, contact our Customer Service Line at 1.866.270.4909. If the address on file is incorrect, the beneficiary will need to contact Social Security Administration to have their file updated. If the beneficiary's file has been updated to reflect a Jurisdiction C address, then just resubmit your claim.
Note: Other issues that could cause a CO-109 denial are HMO enrollment or billing a HCPCS code that would be covered by a different carrier (i.e. local Part B carrier).
- My claim denied CO-58 (Payment adjusted because treatment
was deemed by the payer to have been rendered in an inappropriate or
invalid place of service). The beneficiary received the equipment in
our office. Did this deny in error?
No. Place of service (POS) 11 – Office is not a valid POS for DMEPOS items. For claims submitted to the DME MAC, the place of service is considered to be the place where the beneficiary will primarily use the DMEPOS item. The following is a list of valid POS codes for submission to the DME MAC:
04 Homeless Shelter
09 Prison/Correctional Facility
13 Assisted Living Facility
14 Group Home
16 Temporary Lodging
33 Custodial Care Facility
54 Intermediate Care Facility/Mentally Retarded
55 Psychiatric Residential Treatment Center
65 End Stage Renal Disease Treatment Facility (valid POS for Parenteral Nutrition Therapy)
Coverage consideration for DMEPOS items in a Skilled Nursing Facility (31), unless the beneficiary is in a covered Part A stay, or a Nursing Facility (32) is also considered for certain types of equipment. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6, for a complete list of these items, as well as additional information regarding place of service.
- Why would my claim deny CO-16 (Remark code MA114, claim service
lacks information which is needed for adjudication. Missing/incomplete/invalid
information on where the services were furnished)?
This denial may be related to the information on the claim regarding the facility where the beneficiary is located. For example, if the place of service is 31 – Skilled Nursing Facility (SNF), then block 32 of the CMS-1500 Health Insurance Claim Form would need to contain that SNF's name and address. Likewise, block 32a would need to contain that SNF's NPI number. In a case where block 32 is blank or 32a contains an invalid NPI, and the place of service on the claim is 31, the claim would deny. If the place of service was incorrectly filled out, then resubmit the claim with the correct place of service.
Note: This type of denial cannot be corrected through Reopenings or Appeals. If you have found that you billed incorrectly and received this denial, you must resubmit the claim with the correct information in order for it to process correctly.
- What should I include when writing to Written Correspondence?
It is important to include any information pertinent to your inquiry, including your NPI, PTAN, last five digits of your TIN, and supplier name (or send your inquiry on official company letterhead), and, if appropriate, the beneficiary's name and HICN. This will allow us to respond more specifically to your inquiry. Please also include your name and phone number. For more information regarding written inquiries, as well as inquires in general, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13.
- Why does my claim say CO-45 (Charge exceeds fee schedule/maximum
allowable or contracted/legislated fee arrangement) even though the
When you have a paid claim and there is an ANSI denial reason C0-45, it generally means that your submitted amount was higher than the Medicare allowable for the item you billed. Medicare will only reimburse at the appropriate fee schedule amount. Current and past fee schedule amounts can be obtained by going to the DME MAC Jurisdiction C web page (www.cgsmedicare.com/jc) and clicking on Fee Schedules in the Coverage and Pricing section.
- Who would be an authorized representative for filling out
the Electronic Funds Transfer (EFT) Authorization Agreement form?
An authorized representative is an appointed official of the entity (including, but not limited to, officer, director, manager, general partner, etc.) who has been given the legal authority by the entity to enroll it in the Medicare DMEPOS supplier program, to make changes and/or updates to the entities status in the DMEPOS program, and to commit the entity to fully abide by the laws, rules, and regulations of the Medicare DMEPOS program. A written appointment or delegation of authority is required to be on file with the National Supplier Clearinghouse (NSC) for anyone other than officers of the company and general partners. The person(s) granted the authority of authorized representative must sign the appointment as well to ensure that their signature is on file with the NSC. For more information regarding EFT, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
- What is the time limit for filing a claim? What are my options
when I receive a CO-29 (the time limit for filing has expired) denial?
As a result of the Patient Protection and Affordable Care Act (PPACA), Section 6404, claims with dates of service on or after January 1, 2010, received later than one calendar year beyond the date of service will be denied by Medicare for past timely filing. For example: if your claim has a date of service on March 21, 2010, the claim must be filed by March 20, 2011.
Claims with dates of service prior to October 1, 2009, will be subject to pre-PPACA timely rules and edits (see the timely filing chart in the DME MAC Jurisdiction C Supplier Manual, Chapter 6).
Claims with dates of service October 1, 2009 through December 31, 2009 must be received by December 31, 2010.
For more information about timely filing related to PPACA, please refer to the MLN Matters Article MM6960.
If you have received a denial for past timely filing, you may bill the beneficiary for 20% of the allowed amount; however, you will not receive payment for the other 80%. If you feel you can show good cause for filing late, you may submit a request to reopenings.
- When should I submit a written reopening request versus a
telephone reopening request?
Telephone reopenings are available to handle resolution of minor errors or omissions involving:
- Units of Service
- Service Dates
- Healthcare Common Procedure Code System (HCPCS) coding
- Diagnosis Codes and diagnosis reference
- Modifiers (with the exception of the KX, GA, GZ or GY modifiers. You must submit a Redetermination request in order to add/change/remove these modifiers)
- Place of Service
- Claim incorrectly denied as duplicate charges
If your issue does not involve one of the above scenarios, you should send your reopening request in writing. For more information regarding reopenings please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13.
- What claim documentation should be submitted when billing
for a Continuous Passive Motion (CPM) device (E0935)?
The following information should be included in the claim narrative when billing for an E0935:
- Indication of total knee replacement/arthroplasty either in claim narrative or via ICD-9 Code
- Date of surgery
- Date of application of CPM
- Date of discharge from hospital
Leaving out any of these elements could result in a medical necessity denial.
- Is there a place I can go, other than the IVR, to check claim
Yes. CSI/BE is available for suppliers to check claim status and beneficiary eligibility electronically. For more information on CSI/BE, click here.
- How would I appeal a Medical Necessity (CO-50) denial?
First fill out a Redetermination Request Form. You can find the form by accessing the Forms section of our website. Once the form is completed, you may send it and any documentation supporting payment for your claim to the following address:
CGSYou may also now fax redetermination requests. The fax number for a redetermination request is 1.615.782.4630. For more information regarding appeals, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 13.
DME MAC Jurisdiction C
ATTN: Redeterminations Dept
P.O. Box 20009
Nashville, TN 37202
- When should I bill with a KH modifier rather than KI or KJ?
KH, KI, and KJ are modifiers used with capped rental items and PEN pumps. These modifiers signify which month of the rental is being billed. KH is used only for the first month of rental. KI signifies the second and third months. KJ represents the fourth month through the end of the rental period. It is important that you use these "K" modifiers correctly.
Additionally, if the capped rental item was previously provided to a Medicare beneficiary and a new rental period is now being requested, you must add a narrative to the first month's claim that clearly explains why the item is being replaced (in addition to using the KH modifier) to avoid unnecessary denials. We recommend that you use our Interactive Voice Response (IVR) system at 1.866.238.9650 to verify if equipment was previously provided.
CGS offers an online Modifier Finder Tool which can assist you in determining the correct usage of these (and other) modifiers.
Beginning on August 10, 2009, CGS will no longer provide corrections to "K" modifiers when they are billed incorrectly. These claims will deny with ANSI reason code 182, remark code N56.
If you receive a denial due to either the incorrect billing of the "K" modifier or a missing narrative, you must correct the information and resubmit the claim.
- I am receiving an increased number of claims denying for primary
insurance, what information should I transmit with the electronic file
since I am not allowed to submit a hardcopy of the primary EOB?
When submitting payment information from a primary insurer it is necessary to include the amount billed to the primary; primary adjustment amount; primary approved amount; primary paid amount; and patient responsibility/contractual obligation, including the appropriate CARC code. The appropriate Claim Adjustment Reason Code (CARC) should be used to explain the reason for the adjustment. A complete list of these codes can be found at http://www.wpc-edi.com. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 11 for additional information.
- What type of CMN should I submit to subsequently add portable
oxygen to an existing concentrator?
A revised CMN is required to subsequently add portable oxygen to an existing concentrator. Specific instructions are available in the Oxygen LCD and in Chapter 4 of the Supplier Manual. Please note that if the concentrator was qualified based on a sleep test, a new qualifying test taken at rest or during exercise must be performed in order for the portable to be covered.
- I received a denial indicating that documentation requested
was not received by Medicare and I do not see that I received a request
for additional documentation; what should I do?
It is the responsibility of the supplier to maintain medical necessity documentation, as outlined in the documentation sections of the Local Coverage Determinations (LCD) and documentation chapters (chapters 3 and 4) of the Jurisdiction C DME MAC Supplier Manual. Whenever a claim denies for lack of documentation, it is necessary to request a redetermination with the supporting documentation within 120 days of the original denial for payment consideration.
To request a redetermination, please utilize the DME MAC Jurisdiction C Redetermination Request Form found on the DME MAC Forms Page.
- I received a denial with ANSI Reason Code 172 and I am not
sure why my claims are denying this way, how do I correct these?
ANSI Reason Code 172 occurs when the appropriate certification and/or licensure is not on file with the National Supplier Clearinghouse (NSC). To get the records corrected, suppliers shall obtain the necessary certifications and submit to the NSC for processing. If the certification is already on file with the NSC, contact CGS Customer Service for assistance at 866.270.4909.
- I received a denial with ANSI Reason Code 151 and Remark Code
N362. What causes this denial?
This denial indicates that the number of items provided exceed the acceptable maximum. This denial is related to Medically Unlikely Edits (MUEs). The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. MUEs are confidential and are for CMS and CMS Contractors' use only; therefore, MUE values for specific HCPCS codes cannot be released since CMS does not publish MUEs. Information about MUEs is found at: http://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp
When this denial is received, it is necessary to submit a redetermination with medical documentation supporting the necessity of the items. To request a redetermination, please utilize the DME MAC Jurisdiction C Redetermination Request Form found on the DME MAC Forms Page.
- When do I use the KE modifier?
The KE modifier is meant to be used for supplies and accessories that can be used with both competitively bid and non-competitively bid items. You must only attach the KE modifier when the supply or accessory is being used with a non-competitively bid item. For example, HCPCS code E0981 (Wheelchair Accessory, Seat Upholstery, Replacement Only, Each) can be used with both competitively bid standard and complex rehabilitative power wheelchairs (K0813 thru K0829 and K0835 thru K0864), as well as with non-competitively bid manual wheelchairs (K0001 thru K0009) or a miscellaneous power wheelchair (K0898). If billing the E0981 for use with a K0001 (non-competitively bid), then the KE modifier should be appended to the code. If billing the E0981 for use with a K0823 (competitively bid), the KE modifier would not be used. Please see MLN Matters Number MM6270 for more information regarding the KE modifier.
- Where can I find instructions on using the Interactive Voice
Response (IVR) system?
Links to resources on the IVR can be found on the DME MAC Jurisdiction C Contact Information web page. Go to www.cgsmedicare.com and click on DME MAC Jurisdiction C, then click Customer Service on the menu on the left. When the menu expands, click Contact Other CGS Departments/Resources. These resources include an IVR Script, which details each feature of the IVR and explain how to correctly input information, and also an IVR Flow Chart, which diagrams in a quick reference format the options and information that are available.
- Where can I find phone numbers and addresses for CGS and other
Addresses and phone numbers for Jurisdiction C can be found on the Contact Information page on the DME MAC Jurisdiction C website by clicking Customer Service on the left menu and selecting Contact Other CGS Departments/Resources
You can also find contact information for other DME MACs as well as other Jurisdiction C resources by referring to the DME MAC Jurisdiction C Supplier Manual, Chapter 15.
For a complete list of all Provider Call Center Toll-Free numbers, you may visit The Centers for Medicare and Medicaid Services (CMS) website at: www.cms.gov, click on the MLN Products link in the Top 5 Links section, and click on the Provider Call Center Toll Free Numbers Directory link to download the file.
- Where can I find guidance on filling a claim?
Information on filling claims can be found in the DME MAC Jurisdiction C Supplier Manual. Refer to Chapter 6 for help with paper claims and Chapter 8 for information on electronic claim submission.
- Where should a beneficiary inquire on issues regarding their
All beneficiary inquiries should be handled through the Beneficiary Contact Center. Beneficiaries can contact 1.800.Medicare to receive assistance with their claims.
- Where can I find information on overpayments and refunds?
Where can I get information related to a specific offset?
Information regarding overpayments and refunds can be found in the DME MAC Jurisdiction C Supplier Manual, Chapter 12.
For information regarding a specific offset, contact our Interactive Voice Response (IVR) system. Press option 3 for Payment Information and 3 again for Offset Information. The IVR will ask you for your NPI, PTAN, last 5 of your TIN, and the FCN from your Remittance Advice. The IVR will provide you with the claim details of the original overpayment as well as the overpayment letter date and current offset balance.
- How can I order a paper copy of the DME MAC Jurisdiction C
Supplier Manual and other publications from CGS?
To order paper copies of publications from CGS, you will need to fill out the DME MAC Jurisdiction C Publication Order Form. The form can be found on our website in the Forms section. There is a charge for this service.
It should be noted that all DME MAC Jurisdiction C publications are available free online.
- Where can I find coverage criteria for a specific HCPCS code
Refer to the appropriate Local Coverage Determination (LCD) or Policy Article for information on the coverage criteria for that code or item as well as documentation requirements. A link to the Jurisdiction C LCDs and Policy Articles can be found in the Coverage and Pricing section of our website.
- Where can I find information on workshops and other education
Information on workshops, as well as many other educational opportunities, are made available by our Provider Outreach and Education (POE) team and can be found in the Education section of our website. There you will find dates and sign-up information for Workshops, Seminars, Webinars, and various other educational opportunities and materials. Additionally, if you haven't already, we would recommend that you sign up for our ListServ. By joining the CGS electronic mailing list, you can get immediate updates on all Medicare information, including: Medicare publications, important updates, workshops, and medical review information. To join, click here and fill in the appropriate information.
- Where can I find information on how to fill out the CMS-1500
Health Insurance Claim Form?
Instructions on filling out the CMS-1500 form, as well as descriptions of each block of the form, can be found in the DME MAC Jurisdiction C Supplier Manual, Chapter 6. The Supplier Manual will walk you through each block of the form and indicate what information is required in order to correctly process your claim.
- My claim has denied with ANSI reason code 96 (Non-covered
charge[s]) with remark code M124 (Missing indication of whether the
patient owns the equipment that requires the part or supply). What
can I do to fix this?
This denial is the result of billing a HCPCS code that does not have the required corresponding base equipment on file with Medicare.
- If you are billing supplies or accessories for beneficiary owned equipment, submit a written reopening request along with documentation about the base equipment including the original date of purchase (at least the month and year) and the make/model of the equipment.
- If the information on the base equipment has already been submitted through a different claim and is now on file, then you may simply resubmit your claim.
Call our Interactive Voice Response (IVR) at 1.866.238.9650 prior to submitting your claim to ensure the necessarily base equipment is on file for the item or accessory you are billing. For information on equipment that does not require the DME MAC to set up a CMN/DIF to keep track of payments (for example, diabetic shoes, refractive lenses, or other items that are not capped rental or IRP items) contact our Customer Service line at 1.866.270.4909 for assistance.
- Explain a CO-18 (Duplicate claim/service) denial with remark
code N111 (No appeal right except duplicate claim/service issue. This
service was included in a claim that has been previously billed and
This generally means that we have previously processed (paid, denied, or reduced) a claim for the same HCPCS code and date of service you submitted. Call the Interactive Voice Response (IVR) system to receive the original claim decision information. If the claim paid, then the duplicate denial is accurate. If the original claim denied, use the original denial to establish your next step and appeal time limits. If you believe a claim denied as a duplicate in error, please contact our Customer Service line at 1.866.270.4909 for assistance.
- Where can I find information on the appeals process?
Information regarding the appeals process, rights, and contact information can be found in the DME MAC Jurisdiction C Supplier Manual, Chapter 13.
- How can I order a copy of a Remittance Advice (RA)?
To order a duplicate RA, call our Interactive Voice Response (IVR) system at 1.866.238.9650. Press option 1 for Claims Information, then option 4 to order a duplicate RA. You will need the following information:
- Last five digits of your Tax Identification Number (TIN)
- Payment date
If you do not know the payment date, you may also order a duplicate remittance advice through the claim status option on the IVR. Press option 1 and option 1 again to check claim status. After the IVR gives you information on the processed claim, it will ask you if you want to order a duplicate remittance advice for your claim. To order a duplicate RA via this method, you will need the following information:
- Last five digits of your Tax Identification Number (TIN)
- Beneficiary's Medicare Number (HICN)
- First initial of the beneficiary's first name
- First six letters of the beneficiary's last name
- Date of Service
- How do I correct a CO-4 denial (the procedure code is inconsistent
with the modifier used, or a required modifier is missing)? How do I
determine what the cause is?
There are several possible causes for a CO-4 denial. Use the information below to assist in determining the issue and submit a corrected claim.
- Review the required modifiers for the payment category of the item(s) you are billing. For more information on payment categories and their related modifiers, please refer to the DME MAC Jurisdiction C Supplier Manual Chapter 5.
- If billing for capped rental items with initial dates prior to 01/01/06, or enteral/parenteral pumps, check to see if the purchase option modifier is required. Payment cannot be made past the 11 th rental month without indicating whether the beneficiary has decided to continue to rent or purchase the equipment. For more information regarding the rental/purchase option, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 5.
- If billing with an EY modifier, check to see if there are any other claim lines that do not contain the EY modifier. If a claim line contains an EY modifier, then all other line items on that claim must also contain the EY modifier. If there are items that do not need the EY modifier, they must be billed on a separate claim. For more information regarding the EY modifier, please refer to the MLN Matters Article MM5571.
- If you are billing for an upgrade, it is possible that you billed the modifiers incorrectly. For instructions on how to bill for an upgrade, please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
- Determine whether or not the equipment you are billing is missing a required modifier that indicates whether or not coverage criteria have been met. Refer to the appropriate Local Coverage Determination (LCD) and/or Policy Article to determine if the KX, GA, GZ, or GY modifier is required. If the modifier is required and not present on the claim, it may deny CO-4. Simply add the appropriate modifier and resubmit as a new claim. For more information, please refer to the news article titled IMPORTANT Change – KX, GA, GZ, and GY Modifiers – Claim Rejection dated, July 30, 2009.
- I received a development letter and sent in my documentation.
Now I am receiving a CO-176 denial with a remark code of N115. What
does that mean and how do I fix it?
Generally, a CO-176 denial (prescription is not current) with a remark code of N115 means that upon medical review of the submitted documentation, the physician's order/prescription was either missing or invalid. Review your documentation and submit a redetermination request. Remember to include all pertinent information required to submit an appeal, including each piece of documentation that was requested in the development letter that you previously received.
- I am attaching a CMN electronically but am still receiving
a CO-173 (service was not prescribed by a physician) with remark code
M60 (missing Certificate of Medical Necessity). How do I get this issue
It may be necessary to contact your software vendor or the Common Electronic Data Interchange (CEDI) contractor in order to determine why your CMN is not transmitting electronically. The CEDI contractor may be reached at 866.311.9184 Monday through Friday from 9:00 AM to 7:00 PM Eastern Time. You may also request a written reopening for your claim and include a copy of the CMN; however it is important that any electronic billing issues are resolved as soon as possible to ensure accurate processing of your Medicare claims.If you have received a CO-173 denial with remark code M60, but your CMN is now on file, you can simply resubmit your claim. Use our Interactive Voice Response (IVR) unit to determine if the appropriate CMN is on file by calling 1-800-238-9650 and selecting option 2 (Beneficiary Information), followed by option 2 again (CMN Status).
- My patient received their capped rental DME prior to January
1, 2006, so we have been billing maintenance and servicing (MS) every
six months since the equipment capped at 15 rental months. We were
just paid for the last MS claim two months ago and the patient is now
electing to receive new equipment and has an order from his/her physician.
The reasonable useful lifetime has been met. Do we have to wait the
remaining four months of the MS period prior to delivering new equipment?
No, if the same supplier that delivered the original equipment is delivering the replacement, they may deliver at any time regardless of when the last MS payment was made, so long as the beneficiary elects to receive new equipment and they have a new order from the physician. When billing for the new equipment, please include the RA modifier and a narrative on the claim explaining the situation.
- What is PECOS and how does it affect me as a DMEPOS supplier?
In an effort to ensure that the referring/ordering physician on a DMEPOS claim has a current enrollment record in Medicare and is of a specialty that is eligible to order and refer, all physicians that order/refer DMEPOS items must have updated enrollment information in the Provider Enrollment, Chain and Ownership System (PECOS). This requirement is being implemented in two phases:
- For Phase 1, beginning October 5, 2009, if the referring/ordering physician on a DMEPOS claim does not have current enrollment information in PECOS, you will receive a warning message on your CEDI GenResponse Report.
- For Phase 2, (implementation date to be determined), if the referring/ordering physician on a DMEPOS claim does not have current enrollment information in PECOS, the claim will be rejected.
If you are receiving a warning on your CEDI GenResponse Report that the ordering/referring physician is not enrolled in PECOS, once Phase 2 is implemented your claims containing that physician's NPI will reject unless the physician updates his/her enrollment information in PECOS. Contact the physician to inform him/her of the warning you are receiving so they may take the appropriate action to get the issue resolved. The DME MAC Jurisdiction C Medical Director has written a letter for suppliers to assist them in informing the physician of what needs to be done and how to do it. This letter may be found in the Forms section of our website.
Additionally, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment website at www.cms.gov/MedicareProviderSupEnroll. After accessing the link, click on "Ordering/Referring Report" on the left-hand side.
- How can I check the status of my redetermination request?
You can check the status of a redetermination by calling our Interactive Voice Response (IVR) unit at 866.238.9650. From the IVR main menu, select option 1 (claim information), followed by option 3 (redetermination information), and then option 2 (redetermination status).
To verify redetermination status, you must provide your NPI, PTAN, last five digits of your tax identification number (TIN), the beneficiary's Medicare number, beneficiary's name, and either the DCN from your redetermination acknowledgement letter or claim number (CCN, ICN) of the claim that is being appealed. The IVR will provide the status of your redetermination request, including whether it is pending, reversed, upheld, or dismissed. You may also request a copy of the redetermination decision letter (if the redetermination request has been completed).For more information about the IVR and its abilities, please refer to the IVR Script and Flow Chart by clicking here.
- My claim is denying CO-184 (the prescribing/ordering provider
is not eligible to offer/prescribe/order/perform the service billed).
What can I do?
CO-184 denials must be appealed through Redeterminations. In your appeal, include documentation from the prescribing/ordering provider showing they are eligible to prescribe/order DMEPOS items for Medicare beneficiaries. Be sure to include the provider's correct NPI number and any other necessary documentation (such as the written order) when submitting a redetermination request.
- My claim is denying CO-112 (payment adjusted as not furnished
directly to the patient and/or not documented). I have documentation
showing we delivered the item to the beneficiary or the beneficiary
picked up the item in the store. Why am I receiving this denial?
The claim was denied based on the supporting proof of delivery documentation that was furnished with your claim. Please file a Redetermination request and include proof of delivery and documentation to support the medical need for the item as required by the LCD and DME MAC Jurisdiction C Supplier Manual. Access the Jurisdiction C LCDs and Policy Articles here. To access the DME MAC Jurisdiction C Supplier Manual, click here. Information specific to proof of delivery can be found in Chapter 3 of the Supplier Manual.
- I have a claim that denied CO-16 (claim/service lacks information
which is needed for adjudication) with remark code N109 (this claim/service
was chosen for complex review and was denied after reviewing the medical
records). What does this mean and how do I correct it?
The claim was chosen for complex review. As a result, additional documentation (such as medical records, delivery documentation, progress notes, etc.) was requested and received. Upon review of the documentation, it was found that requested information was either missing, invalid, or insufficient to justify payment.
Review the documentation that you have on file. If you believe the claim should be paid, submit a redetermination request to appeal the decision. Remember to include all of the documentation that was originally requested, as well as any other elements required for a redetermination.
- My claims are denying CO-97 with remark code M2 indicating
that the item(s) billed is included in the payable/allowance for
another service/procedure that has already been adjudicated. What
does this mean?
This denial is the result of the beneficiary being in a Part A covered stay on the date of service. Please refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6 for correct billing guidelines when a patient is in a Part A covered stay.
You can obtain beneficiary inpatient dates by contacting the IVR at 1.866.238.9650 and selecting option 2 for "Beneficiary Information" from the main menu, and then press 1 for "Beneficiary Information." The IVR will provide eligibility dates, deductible, and other insurance information and then will prompt you to select 1 for "SNF/Inpatient Hospital Stay."
- What documentation do I need to support my claim?
Different types of DMEPOS may require different types of supporting documentation. Our website features a series of Documentation Checklists that have been created to assist you in gathering complete documentation. To access these checklists, visit our Medical Review page.
- What do I do when a claim has been returned as unprocessable?
An unprocessable claim is a claim that contains invalid or incomplete information. These claims have no appeal rights and cannot be corrected through the reopening process.
If your claim has been returned as unprocessable, you must resubmit the claim with all the required and valid claim information. For assistance with claim submission, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
- I received a denial with ANSI Reason Code 151 and Remark Code N115. What causes this denial?
This denial indicates that the number of items provided exceeds the usual acceptable maximum. It may also be an indication that another supplier has billed for the same or similar item(s) with overlapping or conflicting dates.
These denials typically must be appealed through redeterminations. Be sure to include documentation that supports the number of units you have dispensed.
To help you avoid overlapping claims for diabetic supplies and shoes, the DME MAC Jurisdiction C IVR offers diabetic supplies and diabetic shoes information. To access this option on the IVR, press option 2 for "Beneficiary Information" from the main menu, and then option 4 for "Diabetic Supplies and Diabetic Shoes Information."
For additional information about the IVR, access the IVR flow chart.
- My claim has denied CO-109, remark code MA-101. What does this mean?
This means that the beneficiary was in a skilled nursing facility (SNF) on the date of service of your claim. Due to consolidated billing rules, if the beneficiary is in a covered Part A Stay, the SNF (and not the supplier) would bill Part A for services rendered, except for certain excluded items. As a result, you would look to the SNF for payment, rather than the beneficiary or the DME MAC.
A complete list of the items excluded from consolidated billing (listed by HCPCS code) can be found on the CMS website at http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html. If a HCPCS code appears on this list, then it may be billed to the DME MAC for payment, even if the beneficiary is in a covered Part A SNF stay.
For more information regarding SNFs and inpatient stays, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 6.
- What do I do if my claim denied for invalid ordering/referring physician information (name and/or NPI)?
If your claim has denied due to invalid ordering/referring physician information, we recommend that you follow these steps:
- Ensure that the physician NPI is correct. All NPI numbers are 10 digits. Contact the physician to be sure that you have the correct NPI.
- Ensure that the physician name is correct. The physician’s name must match the name listed in Provider Enrollment, Chain, and Ownership System (PECOS) exactly.
- Find the physician on the CMS Ordering Referring Report, which can be downloaded on the CMS website at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html. The Ordering Referring Report contains the NPIs and names of physicians and non-physician practitioners who have current records in PECOS and are of a type/specialty that is eligible to order and refer. Verify that the NPI and name match the PECOS records.
- Verify that the physician is eligible to order durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) based on his/her specialty, as listed in PECOS. To find provider specialties, search for the physician’s NPI using the NPI Registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. For a list of physician/practitioner types who may order DMEPOS items, refer to the DME MAC Jurisdiction C Supplier Manual, Chapter 3.
- Resubmit your claim using the correct ordering/referring physician NPI and name.
NOTE: If the physician is not registered in PECOS, then he/she is not eligible to prescribe DMEPOS items.Paper Claim Submitters: If you are eligible under ASCA to submit claims using the CMS-1500 form, you must enter the ordering/referring physician name in block 17 and NPI in block 17b of the claim form. When entering the physician name in block 17, we strongly recommend that you use the “First Name Last Name” format for the physician’s name (rather than “Last Name, First Name”). Submitting the physician’s name in a consistent format helps to ensure that we will correctly process your claim.