Reason Code 5X002: Agree with Provider (Beneficiary Liable)


Reason Code 5X002 — Agree with Provider (Beneficiary Liable) — documentation supports the service provided was not covered and the beneficiary received a valid Advanced Beneficiary Notice (ABN) of non-coverage, therefore the beneficiary is liable for charges incurred on this bill.

To Prevent This Denial

  • If a provider believes that certain otherwise covered items or services will be non-covered (e.g., not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care
  • If a reduction occurs and the beneficiary wants to receive care that is no longer considered medically reasonable and necessary, the ABN must be issued prior to delivery of this non-covered care
  • Issue an ABN at termination if the beneficiary wants to continue receiving care that is no longer medically reasonable and necessary

For more information refer to CMS Internet Only Manuals (IOMs), Medicare Claims Processing Manual Publication 100-04, Chapter 30, Section 30 (PDF, 1.011 KB).





Last Updated: 05/22/2019