Common Reasons for Denial

• Policy frequency limits may have been reached, per LCD

Possible Next Steps

• Review claim submitted for frequency limits listed in LCD and Policy Article and either adjust amounts because of supplier liable or appeal claim with documentation to support medical need
• Consult the Medically Unlikely Edit (MUE) tool to ascertain the maximum allowable units of service that a provider typically reports for a single beneficiary on a given date of service. It's essential to remember that when billing for a 60- or 90-day supply, as permitted by the policy, the claim must feature a narrative in Item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim, as stipulated by the Standard Documentation Requirements for claim narratives. This narrative should clearly specify the duration of the supply (either 60- or 90-day supply). In the event that the narrative was omitted from the claim, a reopening process via telephone or in writing will be necessary to append the required narrative
• Examine the claim to confirm the presence of a narrative when it is necessary in Item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim. Numerous scenarios necessitate a narrative to offer additional details. An instance of this is seen when submitting the same HCPCS code on multiple lines, where distinct strengths are involved for J codes. Follow the reopening guidelines to resolve
• Ensure all questions on Certificate of Medical Necessity (CMN) are qualifying (Required for dates of service prior to January 1, 2023 only)
• A Redetermination request may be submitted with all relevant supporting documentation. 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. Noridian encourages Redeterminations be submitted using the Noridian Medicare Portal

How to Avoid Future Denials

• For frequency guidelines, refer to applicable Local Coverage Determination (LCD), LCD Policy Article
• Review Medically Unlikely Edit (MUE) tool for maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service and the Medically Unlikely Edit (MUE) page for instructions indicating correct billing. Remember to add a narrative to the claim in Item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim where a 60 or 90 supply is permitted per the policy and has 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
• Ensure narrative is included on claim when required
• 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