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Claim Denial Data

Claims may be accepted as filed by Medicare systems but may be denied. CMS and CGS have established claim level editing to ensure services that should not be paid are appropriately denied. Many denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes.

Denials are subject to Appeal, since a denial is a payment determination. There are, however, some denials that can be avoided.

Below is a list of the monthly top denial reasons. Refer to resources available to you to avoid future denials.

Top Claim Denials

Kentucky Ohio Description Resource/Reference

# of Denials:
21,385

# of Denials:
79,505

Duplicate Service

Duplicate claims must be avoided:

  • Check the status of ALL claims before resubmitting
  • Submit multiple same services provided on same date on ONE claim
  • Use appropriate modifier to avoid duplicate denials (e.g., 50, RT, LT)
  • When resubmitting services initially rejected (message code MA130), DO NOT include services that were previously paid
    • For example: A claim is submitted with three line items. Two of the services are paid; one is rejected because the CPT code was invalid. When resubmitting a new claim with the corrected CPT code, do not include the two services previously paid, as they will deny as duplicate.
  • It is also possible that a lab or radiology service has been paid by another contractor to a different provider
    • Be sure to consider services provided by other providers. Review the patient's medical records in full.

ANSI Reason or Remark Code: 18/54/N347

# of Denials:
21,188

# of Denials:
65,591

Non-Covered by this Contractor

Before submitting claims to CGS always check patient eligibility to ensure claims are submitted to the correct payer. Updates made to patient files could cause an overlap in dates/contractors resulting in this type of denial.

  • Refer to the Eligibility section of the myCGS User Manual for navigation steps for using myCGS to check patient eligibility
    • Patient may be enrolled in a Medicare Advantage (MA) plan.
    • Also, refer to the Inpatient section to determine if the service was provided while the patient was registered as inpatient hospital or in a skilled nursing facility (SNF) stay
  • The Interactive Voice Response (IVR)PDF is another option

Also, be sure to submit Part B services to Part B; Part A services to Part A.

ANSI Reason or Remark Code: 109/N104/190/N106 N538

# of Denials:
37,039

# of Denials:
25,383

Non-Covered due to Medical Necessity / Payment Adjusted due to Frequency/Benefit Maximum Reached/Services Not Documented

Some services are processed according to a Local Coverage Determination (LCD) and its accompanying Billing/Coding Article. These resources identify coverage criteria, frequency and other limitations, coding guidelines, and medical necessity. Always refer to the LCDs/Medical Policies webpages to check for an LCD.

ANSI Reason or Remark Code: N115

# of Denials:
9,416

# of Denials:
32,168

Payment is Included in Another Service Previously Adjudicated

Edits prevent our system from paying services that may be included in other services.

  • Verify whether service must be billed with other services. This would apply to "add onExternal Website" codes, for example.
  • Check definition of CPT/HCPCS codes to determine whether the code can be separately billed
  • Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services
  • The status of some CPT/HCPCS codes prevent them for being separately paid
    • Services with a status 'B' are always bundled, as payment is included in other services
    • The status assigned to codes paid from the Medicare Physician Fee Schedule (MPFS) can be reviewed on the CMS Physician Fee Schedule Look-Up ToolExternal Website.

ANSI Reason or Remark Code: N20/B15

# of Denials:
9,241

# of Denials:
29,048

Code Submitted is for Reporting Purposes Only

Some providers are REQUIRED to participate in reporting programs. One method of participating is to submit non-payable codes on claims. The non-payable codes are captured by CMS or our processing system to determine whether the provider successfully reported. In some cases, to determine if an incentive is paid to the provider. In others, so that data can be captured in order to make future changes to the Medicare program.

Programs involved in submitting codes for reporting purposes include:

NOTE: Because reporting is a requirement, this denial is not one that can be avoided.

ANSI Reason or Remark Code: N620

# of Denials:
3,136

# of Denials:
28,790

Provider Not Certified/Enrolled/ or Eligible to Perform or Order/Refer the Service

State scope of practice determines the services providers are allowed to perform, order, and refer. Please refer to this information for specialty-specific details.

Everything regarding credentialing is available to you on Provider Enrollment webpage!

ANSI Reason or Remark Code: N90, MA13, N574

# of Denials:
8,214

# of Denials:
24,364

Non-Covered due to Statutorily Excluded/Routine Service/Service Performed with Preventive Exam

Statutorily excluded services are services that, by law, Medicare cannot pay for. This includes services:

  • Considered routine in nature
  • That do not meet the requirements of a Medicare benefit category
  • Not reasonable and necessary under 1862 (a)(1)
  • Statutorily excluded from coverage on ground other than 1862(a)(1)

Generally, providers are not required to submit claims to Medicare for statutorily excluded services. There are times, however, when the patient requests these services be submitted in order to obtain a denial for secondary insurance purposes. In this case, submit statutorily excluded services with HCPCS modifier GY.

The Advance Beneficiary Notice of Non-Coverage (ABN)External Website, while not mandated, may be provided to Medicare patients as a courtesy, to inform them of their financial responsibility for services that are statutorily excluded from Medicare benefits. The updated ABN form is located at Beneficiary Notices Initiative (BNI) | CMSExternal Website.

Refer to the Correct Coding Initiative (CCI) guidelines to see if codes are "bundled" into other services and if a modifier can be billed to bypass editing.

ANSI Reason or Remark Code: N425

# of Denials:
6,081

# of Denials:
20,885

Medicare is the Secondary Payer

When Medicare is secondary, the primary payer must be billed first

ANSI Reason or Remark Code: 22/MA16/N36

# of Denials:
5,265

# of Denials:
14,260

Expense Incurred Prior to Coverage/After Coverage Ended

Before submitting claims to CGS always check patient eligibility to ensure there is Part B coverage. Also, verify there have been no lapses in coverage.

ANSI Reason or Remark Code: 26

# of Denials:
2,879

# of Denials:
15,350

Patient is Enrolled in Hospice

Patients waive Medicare Part B payments for professional services related to the terminal prognosis when hospice coverageExternal Website is selected. 

  • Exception for professional services of an independent attending physician not employed by the hospice
    • Submit service with HCPCS modifier GV
  • Services unrelated to terminal prognosis may be reimbursed
    • Submit service with HCPCS modifier GW

Allow front-office staff access to myCGS to verify patient eligibility. Check the Eligibility section of the myCGS User Manual for step-by-step instructions on checking for hospice periods.

ANSI Reason or Remark Code: B9

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