CARC 109

Narrative: Consult plan benefit documents/guidelines for information about restrictions for this service.

Reason for Non-Coverage
Laboratory or drug services subject to end stage renal disease (ESRD) consolidated billing.

Claim Denial vs. Rejection: Denial

Appeal Rights: Yes

Patient Responsibility: No

Reference and Educational Material: CMS IOM Publication 100-04, Chapter 16 (PDF, 561 KB), Section 40.6.

Resolution
Payment was made to the ESRD dialysis facility. If the patient is in an ESRD facility, file the claim with that facility.

If the patient is not in an ESRD facility, file an appeal for the denied services.

What to Include in the Appeal?
Lab reports showing the service wasn’t part of ESRD consolidating billing.

Narrative: Consult plan benefit documents/guidelines for information about restrictions for this service.

Reason for Non-Coverage
Physical or occupational therapy services overlap a Part A hospital stay.

Claim Denial vs. Rejection: Denial

Appeal Rights: Yes

Patient Responsibility: No

Reference and Educational Material: CMS IOM Publication 100-04, Chapter 6 (PDF, 682 KB), Sections 10.1, 20.1-20.3.

Resolution
Services are not covered. Our records show that the beneficiary was in the hospital at the time of service.

Payment for rehabilitation services provided to Part A inpatients of hospitals or skilled nursing facilities (SNFs) is included in the respective Prospective Payment System (PPS) rate. Also, for SNFs, but not hospitals, if the beneficiary has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must bill for any rehabilitation service.

Payment may not be made for therapy services to Part A inpatients of hospitals or SNFs, or for Part B SNF residents.

If the patient is inpatient, file a claim to the correct contractor. If the patient is not inpatient, file an appeal for the denied services.

What to Include in the Appeal?
Documentation that indicates the patient was not in an inpatient part A stay.

Narrative: Misrouted claim. See the payer's claim submission instructions.

Reason for Non-Coverage
The claim is for a charge not reimbursed by Part B and should be sent to the Part A Medicare Administrative Contractor (MAC) or the the beneficiary is part of a Health Maintenance Organization (HMO).

Claim Denial vs. Rejection: Denial

Appeal Rights: Yes

Patient Responsibility: No

Reference and Educational Material: CMS IOM Publication 100-4, Chapter 1 (PDF, 1.63 MB), Section 10.1.9.1.

Resolution
Submit the service to the appropriate Part A MAC or the beneficiary's HMO.

Verify whether the patient was enrolled in an HMO. If patient was enrolled in an HMO on the date of service, submit claim to the correct contractor. If the patient is not enrolled in an HMO, submit a claim to the Part B MAC for processing.

What to Include in the Appeal?
If the patient is not enrolled in an HMO, the documentation that must be supplied in your Appeal request would be all medical documentation that supports the necessity of the service based on CMS guidelines.

Narrative: A facility is responsible for payment to outside providers who furnish these services, supplies, or drugs to its patients and residents.

Reason for Non-Coverage
Consolidated billing when there is no patient paid amount.

Claim Denial vs. Rejection: Denial

Appeal Rights: Yes

Patient Responsibility: No

Reference and Educational Material: CMS IOM Publication 100-04, Chapter 6 (PDF, 682 KB), Section 110.

Resolution
Verify whether the patient was not in a skilled nursing facility (SNF) or related to consolidated billing.

If the patient is in a SNF, verify that the service can be billed to Part B. In some cases, a modifier will need to be added. For example, the professional fee may be billed to Part B. In this instance, the 26 CPT modifier may need to be added to the procedure.

If the patient is in a SNF, the service may need to be billed through the SNF to Part A for reimbursement.

What to Include in the Appeal?
Include documentation to support the service billed and show the beneficiary was not in a SNF on the date of service billed.

Narrative: A facility is responsible for payment to outside providers who furnish these services, supplies or drugs to its patients and residents.

Alert: The beneficiary overpaid you for these services. You must issue the beneficiary a refund within 30 days for the difference between his/her payment and the total amount shown as patient responsibility on this notice.

Reason for Non-Coverage
Consolidated billing when there is a patient paid amount.

Claim Denial vs. Rejection: Denial

Appeal Rights: Yes

Patient Responsibility: No

Reference and Educational Material: CMS IOM Publication 100-04, Chapter 6 (PDF, 682 KB), Section 110.

Resolution
Verify whether the patient was not in a skilled nursing facility (SNF) or related to consolidated billing.

If the patient is in a SNF, verify that the service can be billed to Part B. In some cases, a modifier will need to be added. For example, the professional fee may be billed to Part B. In this instance, the 26 CPT modifier may need to be added to the procedure.

If the patient is in a SNF, the service may need to be billed through the SNF to Part A for reimbursement.

What to include in the appeal?
Include documentation to support the service billed and show the beneficiary was not in a SNF on the date of service billed.