The second highest reason code for Medicare claim denials reported for HME providers is OA109: claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
This denial is received when the patient is residing in a skilled nursing facility, a different DME MAC region or is covered under an HMO policy for the date of service. In most regions, a remark code of MA101 will be present when the patient is in a SNF. (A skilled nursing facility is responsible for payment of outside providers who furnish these services/supplies to residents.)
If the patient is in a SNF for those dates of service, if the patient was discharged within two days of the delivery date, the provider can rebill the claim based on the date of discharge. However, it is advisable to have a copy of the discharge summary on hand to prove the actual discharge date in case of a post-pay audit.
When an OA109 denial is received and it is without the MA101 remark code, billers must research in what region the patient resides or in which Medicare HMO they are enrolled. You can research patient eligibility by utilizing your billing software or other online services. (Research online eligibility services prior to signing up. Some services charge a fee, and others offer the service free of charge.)
Based on analysis of 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.
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. She can be contacted at 419/448-5332 or sarahhanna@bright.net.
