Avoiding Denials for Beneficiary Enrolled in a Medicare Advantage Plan

Avoiding denials for reason code 109 and remark code N418 on remittance advice is crucial. These codes signify that the claim was billed to the incorrect contractor, requiring the submission of the claim or service to the accurate payer or contractor. Additionally, they indicate that, for the submitted date of service, the beneficiary was enrolled in a Medicare Advantage Plan. A Health Maintenance Organization (HMO) is a common type of Medicare Advantage Plan.

109 Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.

N418 Misrouted claim. See the payer's claim submission instructions.

To mitigate expenses associated with rework and denials, it is imperative to verify the beneficiary's eligibility on the Noridian Medicare Portal (NMP) before submitting claims. This becomes especially critical when billing for ongoing rental claims. Verification is paramount during specific times, particularly during open enrollment periods and after the first of the year, when beneficiaries may switch to Medicare Advantage Plans or revert to Medicare Fee-for-Service.

The NMP offers a dedicated tab for Health Maintenance Organization (HMO) or Medicare Advantage Plan (MA) verification, ensuring that the correct payer is billed. When verifying eligibility through the HMO/MA tab, suppliers can obtain crucial information such as the insurer's name, plan code number, effective and termination date, Managed Care Organization (MCO) plan type, MCO bill option code, address, phone number, and contract website of the payer. This comprehensive verification process streamlines billing procedures, reduces the risk of claim denials, and promotes an efficient and error-free healthcare reimbursement process.

Last Updated Jan 30 , 2024