Reason Code 119 | Remark Codes M86 - JA DME

Common Reasons for Denial

• Item has met maximum limit for this time period. Payment already made for same or similar procedure within set time frame.

Next Step

• Was item lost, stolen or irreparably damaged (specific incident)?
  • Was RA modifier appended to claim?
    • Appeal when item replaced for lost, stolen, or irreparably damaged (specific incident) with documentation from beneficiary statement, police report, fire report, or insurance claim information, etc. as applicable
• If provided item prior to end of Reasonable Useful Lifetime (RUL) for change in medical condition, an ABN should have been obtained prior to providing item
  • Appeal with medical records that substantiate need for change in medical condition and ABN if obtained
• Is there a similar rental item renting and billing in supplier's system that has not been returned? Two similar items cannot be rented during same month
  • Stop rental item, amounts on AR will need to be adjusted
• Was there a previous supplier within the RUL, and did that supplier continue to bill rental after returned?
  • Adjust amount from AR for that month, ensure that rental was picked up from beneficiary (two suppliers cannot be reimbursed for same month)
• A Redetermination request may be submitted with all relevant supporting documentation for this denial. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Local Coverage Determination (LCD), LCD Policy Article, and Documentation Checklists prior to submitting request to ensure all required documentation is included in request.

How to Avoid Future Denials

• Prior to providing item verify that same or similar item has not been provided
  • The Noridian Medicare Portal can be accessed under Same or Similar, option 2, to verify if beneficiary has had same or similar item or call the Noridian Interactive Voice Response (IVR) System for Same or Similar prior to providing item
• Prior to providing equipment, an Advance Beneficiary Notice of Noncoverage (ABN) may be obtained for items a supplier knows a beneficiary does not qualify for or that will deny as same or similar to an item already in beneficiaries possession
• Was item replaced for lost, stolen or irreparably damaged (specific incident)?
  • Append RA modifier to claim
  • Appeal when item replaced for lost, stolen, or irreparably damaged (specific incident) with documentation from beneficiary statement, police report, fire report, or insurance claim information, etc. as applicable
• If provided item prior to end of Reasonable Useful Lifetime (RUL) for change in medical condition, an ABN should have been obtained prior to providing item
  • Appeal with medical records that substantiate need for change in medical condition and ABN if obtained
• Was there a previous supplier within the RUL, and did that supplier continue to bill rental after returned?
  • Adjust amount from AR for that month, ensure that rental was picked up from beneficiary (two suppliers cannot be reimbursed for same month)
• Are there rental items billing as upgrades and are they correctly billing each month with appropriate modifiers?
  • Refer to the upgrade process on the Noridian Medicare website
• Is there a similar rental item renting and billing in supplier's system that has not been returned?
  • Stop rental item, amounts on AR will need to be adjusted