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Linda Collins Blogger

Understanding Denials: Medicare Claims

Posted by Linda Collins | September 25, 2015

One common reason for claim denial is "lack of medical necessity." Without understanding the details behind this generic denial reason, it is almost impossible to prepare a logical appeal. What resources are available to provide more information about the specific denial? In this two part post, we offer information about resources and online sites to assist with denial research. Today we discuss Medicare claim denials. The next post will discuss private payer denials.

Each of the four DMEMAC regions offers a slightly different option for gathering additional information on a specific claim denial. Below are the basic instructions and links to each of the sites.

NHIC, Region A

The Provider Services Portal (PSP) is a web site tool that can be used by NHIC DME MAC Suppliers. The PSP offers the DME MAC Jurisdiction A supplier community a way to check eligibility, claims status, and offers detailed information regarding audits.

http://www.medicarenhic.com/dme/psphome.aspx

NGS, Region B

Connex offers claims and appeals information to Region B suppliers. Your facility must set up a free account prior to accessing the information.

https://connex.ngsmedicare.com/home/start.swe?SWECmd=Start&SWEHo=connex.ngsmedicare.com

CGS, Region C

The online resource offered by Region C is called "Mr Wizard. In addition to gathering more information about a specific claim, the resource offered through Region C allows you to gather information about all denials for a provider within a specific date range.

https://www.cgsmedicare.com/medicare_dynamic/jc/denials.asp

Noridian, Region D

Endeavor is a secure provider Internet website for Region D suppliers. Eligibility, claims status, and specifics on remit advices are available through this portal.

https://med.noridianmedicare.com/web/jddme/topics/portal

Accessing the claims information through online tools will allow you to see the reason for the denial along with specific information about the claim. This information may be helpful to you as you prepare for appeals. Be sure to have the 14-digit CCN (customer care number, found on the claim or EOB) when you sign on to the site.

Stay tuned for an upcoming R&R post on private payer claim denials. 

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