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Thursday, April 27, 2017

CO 226 , MA 81, N455 Denial codes


CERT Signature Denials


Denial Reason, Reason/Remark Code(s)

CO-226: Information from the billing/rendering provider was not provided or was insufficient/incomplete

MA81: Missing/incomplete/invalid provider/supplier signature

Resolution/Resources:

The CERT review contractor assesses errors when signatures in practitioners’ medical records, including X-ray reports and orders, do not meet Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within 120 days of the date shown on the remittance advice notice of the denied services.  

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal with Palmetto GBA.

Please clearly indicate 'CERT' when completing the redetermination form


Absence of Valid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N455: Missing physician order

Incomplete/Invalid Orders/Requisitions/Documentation of ‘Intent’

CO-226: Information from the Billing/Rendering Provider was not provided or was insufficient/incomplete

N456: Incomplete/invalid physician order

Resolution/Resources

The CERT Review Contractor assesses errors when there is no evidence of 'intent' or documentation of the request, in accordance with Medicare requirements. As a result, Palmetto GBA must initiate claim adjustments and recoup any related overpayments from providers. For denial purposes, these messages will be applied in situations involving ordering-treating physicians or qualified non-physician practitioners.

If you received Medicare Remittance Advice notification of these errors and disagree with the denials, send a written request for a redetermination (appeal) to Palmetto GBA. A redetermination is the first level of appeal and must be requested within
120 days of the date shown on the remittance advice notice of the denied services.

Do not refile the claim. The decision for the denial was based upon CERT’s review of medical records; therefore, it can only be resolved by filing an appeal.

Please clearly indicate 'CERT' when completing the redetermination form


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