Top Denials For Medicare Texas And Claim Reason Codes

Are you tracking your denied claims on a daily basis for correction and refiling of these claims?  When a claim is denied on the first pass submission you will only receive the electronic rejection notice.  Below are the top 5 reason for denial of Texas Medicare Claims and how to fix the claims:

  • 96- Non covered charge. This service is not covered by Medicare.  You can bill the patient only if you obtained a date and service specific Advanced Beneficiary Notice (ABN)  from the patient explaining that this service may not be covered by Medicare.   You can find more information about this form and when to use it at the following link -https://www.cms.gov/medicare/medicare-general-information/bni/abn.html
  • 109- Claim not covered by this payer contractor.  Did you check the benefits when the patient came in?  In most cases, this indicates the patient has a Medicare replacement plan instead of traditional Medicare.   Contact the patient or check Novitasphere and obtain the correct insurance information and file the claim to the Medicare replacement plan.
  • 18- Duplicate Claim/Service.  Did you already file the claim to Medicare?  Check the Medicare IVR to see if there is already a claim in process or paid for this service.
  • 29- Time limit for filing has expired.   Claims must be filed within one year from the date of service for Medicare beneficiaries.  If the claim has been previously filed, within the filing deadline,  an  appeal can be filed with the proof of timely filing.  If the claim was not originally filed timely then you do not have any appeal rights.

Staff should be checking these denials daily to make sure all claims that were submitted are received and in process.  If the claims are denied on the first pass with one of the above rejections you will not receive an ERA/EOB with the denial information, this electronic reject is your only notification so it is very important to work these denials daily.  

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s