Common Reasons for Denial

• Item billed may require a specific diagnosis or modifier code based on related LCD
• A development letter requesting additional documentation to support service billed was not received within provided timeline
• Item being billed does not meet medical necessity
• CMN is in denied status

Next Step

• If CMN is in denied status, work with Supplier Contact Center to determine what was wrong with CMN, once that is determined, appeal claim
• If the remittance advice reason includes MA130, correct claim and rebill
• Suppliers may do a self service reopening in the Noridian Medicare Portal to adjust diagnosis based on medical records available to supplier.
• 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

• Review beneficiary's medical records to determine if a diagnosis that qualifies is indicated
• Review related LCD for modifier criteria
• Respond to development letters with supporting documentation within designated timeline as defined on letter
• Ensure all questions on Certificate of Medical Necessity are qualifying according to policy (Required for dates of service prior to January 1, 2023 only)
• 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