Medicare Top Ten Denials and action - Non covered services

The action - Denied as Non covered service


MRA reason code PR-96: Non-covered charge(s).

· Remark message N115: This decision is based on an LMRP or LCD. An LMRP/LCD
provides a guide to assist in determining whether a particular item or service is covered.

MRA reason code PR-204: This service/equipment/drug is not covered under the patient’s current benefit plan.
· Remark message N103: Social Security records indicate this patient was a prisoner when the service was rendered. This payer does not cover items and services furnished to an individual while he is in state or local
custody under a penal authority unless, under state or local law, the individual is personally liable for the cost of his health care while incarcerated and the state or local government pursues such debt in the same way and with the same vigor as any other debt.

Resolution

The MRA messages above are examples of some that may appear when providers bill/report services that are non-covered under the Medicare program.

Medicare exclusions include, but are not limited to: personal comfort items; self-administered drugs and biologicals (i.e., pills and other medications not administered by injection); cosmetic surgery (unless to repair an accidental injury or improvement of a malformed body member); eye exams (for purpose of prescribing, fitting or changing eyeglasses or contact lenses in absence of disease or injury to eye); and routine immunizations. So we can't bill for these services.

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