Working Down Denials
PR16 Claim service lacks information needed for adjudication
National Government Services, the Jurisdiction B DME MAC,
recently addressed issues with claims filing resulting in a PR16
denial code with an M124 remark code. This denial represents
equipment that was not paid for by Medicare fee-for-service (only
equipment that was paid for by other insurance or by the
beneficiary) and supplies that are provided after the patient
transitions to Medicare FFS.
For supplies and accessories used with beneficiary-owned
equipment that was not paid for by Medicare FFS, all of the
following information must be submitted with the initial claim in
Item 19 on the CMS-1500 claim form for paper claim submitters or in
the NTE segment for electronic claim submitters:
- HCPCS code of base equipment; and,
- A notation that the equipment is beneficiary owned; and,
- Date the patient obtained the equipment.
Example: E0601, Continuous airway pressure device, Beneficiary
Claims for supplies and accessories must include all three
pieces of the information listed. Claims lacking any one of the
elements will be denied with the PR16 and a remittance remark code
of M124, which indicates the charge is denied because it is missing
an indication of whether the patient owns the equipment that
requires the part or supply.
In the past, the only course of action providers had to correct
these issues was to go through the appeals process. However, on May
8, a change was made to the Medicare claims processing system that
allows the opportunity simply to resubmit these claims for payment
with the additional information in Item 19 or the NTE segment.
Providers can receive payment quicker if they refile these
claims. If you have previously submitted a claim that received this
denial to redetermination and would rather resubmit the claim you
may do so, as opposed to waiting for a redetermination decision. If
you choose to refile your claim(s), NGS will simply dismiss your
request for redetermination.
Currently, NGS seems to be the only DME MAC reprocessing these
denials in this matter. Jurisdictions A, C and D still require a
redetermination. But keep your eyes open for listserv messages from
those jurisdictions for any changes. Sometimes when one DME MAC
makes a change, the others follow.
Based on analysis of Medicare claims adjudicated by the four
DME MACs in the first quarter of 2009, there were 9,350 PR16
denials. Source: RemitDATA, 866/885-2974, www.remitdata.com
Read more Working Down Denials
Sarah Hanna is a reimbursement consultant and vice president
of ECS Billing
& Consulting, Tiffin, Ohio, and specializes in proper
billing protocols, Medicare coverage guidelines and billing office
procedures. You can reach her at 419/448-5332 or email@example.com.
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