CMS Establishes Denial Codes for Processing NCB Claims

BALTIMORE–In a Change Request sent to the DME MACs on Friday,
CMS established a number of denial reason codes to be used when
processing claims under national competitive bidding.

Among the new denial codes:

–45: “Charge exceeds fee schedule/maximum allowable or
contracted/legislated fee arrangment,” to be used when the
submitted charge on the claim is higher than the allowed charge;
and
–96: “Non-covered charge(s),” to be used when denying claims for a
beneficiary who resides in a CBA who obtains an item from a
non-contract supplier that has not obtained a signed ABN.

The Change Request, No. 6069, noted three new reason codes when
denying claims under NCB where a contract suplier submits a claim
for oxygen equipment after the payment cap has been reached
(maximum of 45 total payments for the beneficiary), or when the
payment cap for a capped rental item has been reached (maximum of
25 total payments for the beneficiary):

–B7: “This provider was not certified/eligible to be paid for
this procedure/service on this date of service.”
–N211: “Alert: You may not appeal this decision.”
–N307: “Billing exceeds the rental months covered/approved by the
payer.”

The new denial codes are effective July 1 with an implementation
date of July 7, according to the Change Request.