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Top Five Claim Denials and Resolutions – Medical Necessity Denials

LCD/NCD Denials

The Remittance Advice will contain the following codes when this denial is appropriate.

CMS houses all information for Local Coverage or National Coverage Determinations that have been established.  Those are housed at the Medicare Coverage Database.

Resolution

Check the LCD or NCD prior to service to determine eligibility of services for patient.  If the service being performed is not covered under the LCD guidelines, we encourage you to provide your patients with an ABN prior to performing these tests.

LCD Reconsideration Process: To request changes to any existing LCD, fax clinical evidence/documentation directly to CGS through our Medical Director.

Routine Services

The Remittance Advice will contain the following codes when this denial is appropriate.

Resolution/Resources

Statutorily Excluded/ Non Covered Services

The Remittance Advice will contain the following codes when this denial is appropriate.

Reason Code CO-96: Non Covered Services

Advance Beneficiary Notice (ABN) Information

ABN Notices, and How They Are Used

ABNs allow Medicarepatients to make an informed decision about whether to receive a service that is likely to be non-covered on the basis of “not reasonable and medically necessary”. If you have a signed, valid ABN on file and your office receives a Medical Necessity denial for services, you may collect the billed amount from the patient for the services indicated.

The Requirements of the ABN

Providers must use the CMS-R-131 Form, which can be copied on your letterhead.  It must be given to the patient in advance of the service being rendered, and must cover all services that are being provided that may not be covered.  Repetitive notices are acceptable, if necessary.  The ABN may be completed prior to the patient's arrival for the provider's convenience (Blanks A-F), with the beneficiary or representative responsible for filling out their section (Blanks G-I).  Keep a copy of the ABN in the patient's file for documentation purposes.  A copy must also be provided for the patient.

When should the ABN be used?

If medical necessity is not met, or if the patient is receiving a screening service with frequency limitations, then the ABN should be delivered as described above.

What if the patient refuses to sign the ABN Form?

Make sure to verbally review the ABN with the patient, and document their refusal to sign.  A witness should sign and date the form. 

If you have obtained a valid ABN, submit a claim for the service(s) with HCPCS modifier GA. Refer to CGS Modifier Lookup tool for more information on HCPCS modifier GA.

Additional information related to the proper use of the ABN can be found on the CMS Beneficiary Notice Initiative Website.

The provider can refer the patient to their "Medicare and You" handbook for the complete list of excluded services. 


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