Notifying Patient of Service Denial

100.6 - Notifying Patient of Service Denial (Rev. 3220, Issued: 03-16-15, Effective: ICD-10: Upon Implementation of ICD-10, ASC-X12: 01-01-12, Implementation: 10-01-14, ICD-10: Upon Implementation of ICD-10 ASC X12: 09-16-14) Services may be noncovered because they are statutorily excluded from coverage under Medicare, or because they are not medically reasonable and necessary. If a service is excluded by statute, the CORF may submit a claim for them to Medicare to obtain a denial prior to billing another insurance carrier. It shows the charges as noncovered, and includes Condition Code 21. It may bill the beneficiary for the excluded services, and need not issue an advance beneficiary notice (ABN). However, when providing therapy services under the financial limitations, the CORF should provide the beneficiary with the Notice of Exclusion of Medicare Benefits (NEMB). The Medicare Claims Processing Manual, Chapter 30, “Limitation on Liability,” discusses ABNs for A/B MAC (A) processed claims for Part B services. If, after reviewing the plan of care, the CORF determines that the services to be furnished to the patient are not medically reasonable or necessary, it immediately provides the beneficiary with an ABN. If the patient signs an ABN, the claim includes occurrence code 32 “Date Beneficiary Notified of Intent to Bill (Procedures or Treatments)” along with the date the ABN was signed. If the beneficiary insists that a claim be submitted for payment, the CORF must indicate on the bill (billed separately from bills with covered charges) that it is being submitted at the beneficiary’s request. This is done by using condition code 20. If during the course of the patient’s treatment the A/B MAC (A) advises the CORF that covered care has ceased, the CORF must notify the beneficiary (or the beneficiary’s representative) immediately. NOTE: Information regarding the form locator numbers that correspond to these data element names is found in Chapter 25.