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Linda Collins Blogger

Denials

Posted by Linda Collins | July 21, 2017

An EOB (Explanation of Benefits) or RA (Remittance Advice) provides information about the reason for denied claim. Taking time to understand the reason for denial is important in determining the next steps in the payment process.

The EOB or RA provides an explanation of services covered and the reimbursement amount. If there is a denial for any of the services submitted on the claim, the form will provide a reason code for the denial. The denial codes are standardized codes used by Medicare or the private payer to summarize and categorize claim denials. It is important to understand the reason for denial in order to determine your appeal rights.

Medicare provides a listing of the common denial codes, the definition of these codes, and a suggestion for processes to reduce the denials in future claims. Learn more about the denial codes here. You can click on any denial code to get more information about that particular denial.

One common denial is N115/50, lack of medical necessity. It is easy to make assumptions about the reason for the lack of medical necessity, but in order to establish a valid appeal; you must research the claim a bit more. In order to do this, you can access provider portals available through the DME MACs. These portals allow you to obtain details about the reason for denial. Access to these portals requires you to register with the MAC. The practices using these portals are able to quickly research denials, file appeals or update internal processes to prevent the denial in the future.

You may learn more about the provider portals for each DME MAC below:

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