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 December in all of Medicare Jurisdiction H, according to the region’s Medicare Administrative Contractor (MAC).
“Prior to performing or billing a service, ensure that the service is covered under Medicare,” Novitas Solutions says on their website.
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 (§20);
- No legal obligation to pay for or provide (§40);
- Paid for by a governmental entity (§50);
- Not provided within United States (§60);
- Resulting from war (§70);
- Personal comfort (§80);
- Routine services and appliances (§90);
- Custodial care (§110);
- Cosmetic surgery (§120);
- Charges by immediate relatives or members of household (§130);
- Dental services (§140);
- Paid or expected to be paid under workers’ compensation (§150);
- Non-physician services provided to a hospital inpatient that were not provided directly or arranged for by the hospital (§170);
- Services Related to and Required as a Result of Services Which are not Covered Under Medicare (§180);
- Excluded foot care services and supportive devices for feet (§30); or,
- Excluded investigational devices (See Chapter 14).”
Did any of these catch you by surprise such as “Resulting from war” or “Routine services and appliances?”
Services Resulting from War
Sure enough, Section 70 Services Resulting from War says, “Items and services which are required as a result of war, or of an act of war, occurring after the effective date of the patient’s current entitlement date are not covered.”
Routine Services and Appliances
That’s right: Routine physical checkups (excluding those services deemed “preventive” under the Affordable Care Act) are not covered under Medicare Part B. Eye and hearing examinations and immunizations aren’t covered either. According to Section 90:
The routine physical checkup exclusion applies to (a) examinations performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury; and (b) examinations required by third parties such as insurance companies, business establishments, or Government agencies.
The exclusions do not apply to physicians’ services (and services incident to a physician’s services) performed in conjunction with a disease such as an eye exam for someone with glaucoma or a hearing exam for someone with Meniere’s disease. Medically necessary treatment of complications of implantable hearing aids, such as medically necessary removals of implantable hearing aids due to infection, may be covered. Likewise, vaccinations and immunizations may be covered if they directly relate to the treatment of an injury or direct exposure to a disease or condition.
Medicare lists some such examples:
Tetanus antitoxin or booster;
Immune globulin; and
Anything specifically covered by statute (Chapter 15).
Resolve EOB 96 Errors
The distinction for when a service is covered or noncovered is what leads to the prevalence of claims denials for noncoverage. Front desk staff generally do not know the specific nature of every patient visit. The only recourse is to verify coverage prior to services being rendered.
For more information about prior authorizations, read:
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