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Wednesday, June 22, 2016

Provider was not eligible for this procedure - Denial code B7 and B9

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?
Provider was not certified/eligible to be paid for this procedure/service on this date of service.

A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, or when a procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or a laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification
 Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.


Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?
Patient is enrolled in a hospice.

A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.

The following situations require a modifier be applied to the claim prior to submission.

• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
• Claim should be submitted with modifier GV.
• If claim was submitted with the GV modifier, check patient's file to verify that the attending physician is not employed by the hospice provider.
• Services not related to the hospice patient’s terminal condition:
• Claim should be submitted with modifier GW.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.
• If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.

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