Reason Code 109 | Remark Codes N538

Code Description
Reason Code: 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Remark Codes: N538 A facility is responsible for payment to outside providers who furnish these services/supplies/drugs to its patients/residence.

Common Reasons for Denial

  • Beneficiary was inpatient on date of service billed

Next Step

  • If wrong date of service was billed, suppliers may do a self service reopening in the Noridian Medicare Portal. When provided within 2 days prior to anticipated discharge to home, the discharge date must be billed
  • If beneficiary was not inpatient on date items were provided, contact the facility to update their billing. You can find the NPI of the facility through the claim status page under expanded denial details of the NMP for that specific claim. Once that billing update is verified through Self Service, supplier can either do a self service reopening or rebill the claim for the correct date of service.

How to Avoid Future Denials

  • Verify correct date of service is billed. If item was provided within 2 days prior to an anticipated discharge to home, the discharge date must be billed. Payment cannot be made by DME MAC for items received while a beneficiary is in a Part A stay unless equipment was delivered no more than two days prior to anticipated discharge to home
  • Suppliers may use the Noridian Medicare Portal, under eligibility, to verify if beneficiary is inpatient.
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