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.