Topic
Rejection
When Used / How to Resolve
Ambulance
Transportation to/from this destination is not covered.
Ambulance services to or from a doctor’s office are not covered. While transporting a patient, when the ambulance must stop at a physician’s office because of the dire need for professional attention, and immediately thereafter proceeds to a hospital or critical access hospital, the services may be covered. Refer to HCPCS modifier X.
Ambulance
Transportation to/from this destination is not covered.
Transportation to a facility to be closer to home or family is not covered. Medicare only covers ambulance transport to the nearest appropriate facility. An appropriate facility is typically an institution equipped to provide the needed hospital or skilled nursing care that the illness or injury involves.
Ambulance
Transportation to/from this destination is not covered.
Ambulance service to a funeral home is not covered.
Ambulance
Transportation in a vehicle other than an ambulance is not covered.
A patient whose condition permits transport in any type of vehicle other than an ambulance would not qualify for ambulance services under Medicare.
Screening Colonoscopy HCPCS Code G0105
Service is not covered unless the beneficiary is classified as a high risk.
Medicare coverage for a screening colonoscopy is based on patient risk. For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 10 years, but not within 47 months of a previous screening flexible sigmoidoscopy. Refer to HCPCS code G0121.
Eligibility Issues
Social security records indicate that this patient was a prisoner when services were rendered.
Medicare does not pay for these services because they are payable by another government agency. The claim has to be submitted to that agency.
  • We will not cover items and services furnished to an individual while they are in state or local custody under a penal authority
Eligibility Issues
Social security records indicate that this individual has been deported.
Medicare does not cover items and services furnished to individuals who have been deported.
Medicare Secondary Payer (MSP)
We do not pay for this as the patient has no legal obligation to pay for this.
If the primary insurance does not hold the beneficiary responsible for a service due to a contractual obligation between the provider and the primary insurance, the patient is not liable.
  • If the beneficiary is not legally obligated, we will not make payment
Electronic Claim
Not covered unless submitted via electronic claim.
The Administrative Simplification Compliance Act (ASCA) prohibits Medicare coverage of claims submitted to Medicare on paper, except in limited situations.

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Provider Contact Center: 877-567-7271

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