Thursday, March 27, 2014

Denied as - rendering provider not eligible to perform the service, missing / invalid HCPC or NDC code

Claim Errors (Remittance Advice Remarks) 

•  The rendering provider is not eligible to perform the service billed (185) or claim/ service lacks information which is needed for adjudication. (16/MA30)
o Service code not covered to the provider type or specialty Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:
•  The request must submitted in writing
•  The request must be supported with documentation
o documentation should include any claim  examples or indicate why the code should be payable
•  If there is no supporting documentation, the request will not be considered.

•  Missing/incomplete/invalid HCPCS Code (A1/M20)
o Validate code keyed correctly
o Validate code is current for Date of Service (DOS)

•  Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)
o For resolution to these denials, please refer to  Select Drug Code/NDC Drug Information. NDC, unit of measure and units should be submitted on Medicare primary claims  even though not required by Medicare) so the information will cross over to Medicaid, eliminating  the need to submit Medicaid secondary claims on paper.
•  Incomplete/invalid plan information for other insurance (Invalid Medicare Action Code) (16/N245)
o Claims denied by Medicare and submitted electronically must include a Medicare Action Code (MAC)

•  This service/equipment/drug is not covered under the patient‟s current benefit plan (204)
o Non-covered WV Medicaid Service

•  This case may be covered by another payer per coordination of benefits/secondary
 payment cannot be considered without the identity of or payment information from the primary payer.  The information was either not reported or was illegible. (22/MA04)
o Payer information is not submitted on electronic claim
o Explanation of Benefit (EOB) is not submitted with paper claim
•  Charges are covered under a capitation agreement/managed care plan (24)
o For members enrolled in Medicaid MCO – MCO is responsible for the service
o For Members who have a PAAS provider, PAAS approval is required
–View member‟s Medicaid Card to verify MCO or PAAS information
–Utilize AVRS to verify MCO or PAAS information

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