Non Covered Denials

The No. 1 claim error for June in 11 states plus the District of Columbia was for non-covered charges, according to Novitas Solutions, Medicare Administrative Contractor for Jurisdictions H (Arizona, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas) and L (Washington DC, Delaware, Maryland, New Jersey, and Pennsylvania).

This error is identified by Explanation of Benefits (EOB) message code 96. Noncoverage has been the No. 1 claim error for some time in these states, which is hard to believe because there’s a known cause and cure.

Non-coverage Denials-Cause and Cure:
Explanation of Medicare Benefits (EOB) error message 96 Non-covered charge was the No. 1 reason for claims denials in all of “Prior to performing or billing a service, ensure that the service is covered under Medicare,Medicare Jurisdiction H, according to the region’s Medicare Administrative Contractor (MAC).

Please verify “Prior to performing or billing a service, ensure that the service is covered under Medicare,” This should be a no brainer, but there are quite a few services you would think are covered by Medicare that aren’t.

For example, according to Medicare Benefit Policy Manual Pub. 100-02, Chapter 16, Section 10, “No payment can be made under either the hospital insurance or supplementary medical insurance program for certain items and services, when the following conditions exist, 

  • Not reasonable and necessary
  • No legal obligation to pay for or provide
  • Paid for by a governmental entity
  • Not provided within United States
  • Resulting from warPersonal comfort
  • Routine services and appliances
  • Custodial care
  • Cosmetic surgery
  • Charges by immediate relatives or members of householdDental services
  • Paid or expected to be paid under workers’ compensation
  • Non-physician services provided to a hospital inpatient that were not provided directly or arranged for by the hospitalTop Claim Error Revealed
  • Services Related to and Required as a Result of Services Which are not Covered Under Medicare
  • Excluded foot care services and supportive devices for feet or,Excluded investigational devices (See Chapter 14) 

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