Common Reasons for Denial

• There is a date span overlap or overutilization based on related LCD.
• Policy frequency limits may have been reached, per LCD

Next Step

• To adjust date span based on medical records available to supplier, suppliers may do a self-service reopening in the Noridian Medicare Portal
• 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
• 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.
• 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.

How to Avoid Future Denials

• To avoid overlap, review previous claim submissions and date spans
• 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.
• 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
• The Noridian Medicare Portal can be accessed under Same or Similar, option 1 or 2, to verify if beneficiary has had same or similar item or call the Noridian Interactive Voice Response (IVR) System for Same or Similar