• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

What should take place

Messages
9
Best answers
0
I have a question our retail pharmacy billed J7192(Factor XIII) to Medicare part B but it is being rejected through the clearing house stating we need to bill the correct payor/contractor. I called Medicare and they said it will pay under part B under special situations and I looked on the LCD and we billed it with 286.0 which is covered under the LCD. but all the articles we have read it takes us to inpatient and or SNF. So my question is should this have been billed to Medicare part A?
 

masequap

New
Messages
9
Best answers
0
Check for other insurance

Per CMS, reason code 109 is:

Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. This change effective 11/1/2012: Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

You should start by making sure that the patient does not have another primary insurance besides Medicare.

Check your contractor's website. I live in CT and our contractor is NGS. Per NGS:

OA 109 Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor Many times Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, instead of “traditional fee-for-service” Medicare. Medicare Advantage plans, sometimes called “Part C” or “MA plans,” are health plans offered by private companies approved by Medicare.

Medicare pays a set amount of money to these private health plans for their members' health care and claims must be sent to the plan.

Suggestions to reduce or eliminate these kinds of claim denials:

Patient screening during registration is very important to identify those patients that have joined a Medicare Advantage plan.

The IVR provides patient eligibility and benefit information (including MA information) to assist in determining if Medicare should be billed or if the patient has an MA plan that should be billed instead of Medicare. View the IVR Web page for assistance with calling the IVR.

On this page is a helpful tool, the Part B Touch-Tone/Eligibility Checklist (249 KB) that will aid you in tracking patient eligibility.

During patient registration, it is important for office staff to identify whether a beneficiary's claims should be covered by other insurance before, or in addition to, Medicare. This information helps determine who to bill and how to file claims with Medicare.

I hope this information helps you on your journey.
 
Top