Top Three Claims Denial Reasons
Information about the top three reasons claims submitted to Medicare may be denied.
According to a recent DME MAC webinar, the top three reasons for claims denials are:
- Claim not covered by payer/contractor
- Claim not paid by this payer/contractor
- Duplicate claims/service
What Does This Mean for You?
If a patient is enrolled in a Medicare Advantage Plan, the claim must be submitted to that payer and not to the DME MAC. You may resubmit a claim to the Medicare Advantage Plan if you incorrectly submitted it to the MAC and received a denial with error CO-109, N418.
DMEPOS claims for Medicare beneficiaries are always submitted to the DME MAC jurisdiction where the patient resides. This is the address on file with Medicare. If you received denial code CO-109 N104, MA130, MA37 you may resubmit to the appropriate DME MAC.
Duplicate claims are automatically denied with no rights to appeal. You may file a redetermination on the original claim is you disagree with how it was processed.
Check the Provider Portal for the appropriate DME MAC to obtain more information.
JA, JD: https://med.noridianmedicare.com/web/jddme/topics/nmp