CO 22 and 109
This care may be covered by another payer per coordination of benefits. Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
Submit the claims to Primary carrier. If patient said there is no primary insurance then ask patient to call Medicare and update as Medicare is primary. After this process resubmit the claims and it will be processed.
Q: We received a denial with claim adjustment reason code (CARC) CO 22. What steps can we take to avoid this denial?
This care may be covered by another payer per coordination of benefits.
A: This denial is received when Medicare records indicate that Medicare is the beneficiary’s secondary payer.
To prevent this denial in the future, follow these steps before submitting claim to Medicare. If Medicare is the secondary payer, send claim to primary insurer for a determination before submitting to Medicare for a possible secondary payment.
• Ask patient/representative to complete the Medicare Secondary Payer (MSP) Questionnaire external pdf file to help determine if Medicare is the primary or secondary payer.
Check patient eligibility and verify if Medicare is the secondary payer via the Secure Provider Online Tool (SPOT) or the interactive voice response (IVR) system. If Medicare is secondary, the following MSP details will be provided:
• Via SPOT:
• Effective date
• Termination date
• Insurer name
• Policy number
• Type of primary insurance
• Address
• Via IVR:
• Type of primary insurance
• Effective and termination date for all valid insurers for a current or previous date of service.
To resolve the denial:
• Contact patient/representative and ask if patient insurance has changed. The Medicare Secondary Payer (MSP) Questionnaire external pdf file may also be completed at this time to help determine if Medicare is primary or secondary.
• If patient insurance has changed, update your files for future reference.
• To update patient Medicare records, you may place a conference call with the patient/representative and the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.
• If patient file is updated to indicate that Medicare is the primary payer on the date(s) of service, resubmit the claim to Medicare.
• If Medicare is secondary, submit the claim to the primary payer for processing. After determination is made by the primary insurer, submit claim to Medicare for possible secondary payment
Denial Reason, Reason/Remark Code(s)
CO-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
CO-N104: This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS website at http://www.cms.gov/ external link
CA-N418: Misrouted claim. See the payer’s claims submission instructions.
Resolution/Resources
The most common reasons that claims are denied as ‘submitted to incorrect program’ are:
The item is a supply, orthotic, or prosthetic or is an item of medical equipment
The beneficiary is in a Medicare Advantage (MA) plan
Medical Equipment or Supply Denials
Submit to Palmetto GBA:
Most implanted durable medical equipment (DME) and related supplies must be submitted to Palmetto GBA, not to the DME Medicare Administrative Contractor (DME MAC)
Many splint and casting procedure codes must also be submitted to Palmetto GBA
Some supplies must be submitted to Palmetto GBA. It is important to note that even though these supplies are considered ‘carrier jurisdiction’ (not DME MAC jurisdiction), many supplies are not reimbursed separately if they are provided ‘incident to’ a physician’s service
Submit to the DME MAC:
Submit DME claims to CGS Administrators, LLC (CGS)
Most non-implanted DME, orthotics and prosthetics must be submitted to the DME MAC
MA Plan Denials
Verify patient eligibility for Medicare Part B prior to submitting claims to Palmetto GBA through the Palmetto GBA eServices external link portal or Interactive Voice Response unit (IVR)
CO 24 and CO 120
Charges are covered under a capitation agreement/managed care plan Patient is covered by a managed care plan.
As per Medicare, patient has Medicare advantage plan or HMO plan. Check the Medicare eligibility through IVR and find the HMO information or call the patient and get the information. File the claim to HMO.
