Medicare denial reason MA 01, PR 49, 96 & 204, MA 130

Denial code -  ma01


MA01    Alert: If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.


What we can do - This is the general denial and see addition code for exact denial. For this type of denial we can appeal the along with required documents

Denial reason code ma130



MA130    Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

What we can do - This is the general denial and see addition code for exact denial. However we cant appeal this claim since it is not denied and it has been rejected. Just correct the error an appeal



Medicare Denial reason pr 49

These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.


What we can do - PR - stands for Patient responsibility. Hence we can bill the patient. However check your CPT and DX before bill the patient.


Action : Check the CPT and ICD, confirm if we billed correctly, then check the patient eligibility benefit and confirm if the service is Non covered under patient plan. Then bill the patient.

Avoiding denial reason code PR 49 FAQ

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?

Routine examinations and related services are not covered.

A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.

• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services, for routine or screening purposes, such as an annual physical.

 Medicare does cover certain preventive services.

Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.


• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.

Medicare reason code PR 96


Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.)

Start: 01/01/1995 | Last Modified: 06/30/2006

What we can do - See the additional remark code for exact reason and act accordingly.


Medicare reason code pr 204


204    This service/equipment/drug is not covered under the patient’s current benefit plan Start: 02/28/2007


What we can do - PR - stands for Patient responsibility. Hence we can bill the patient. However check your CPT and DX before bill the patient.


We need to check eligibility, benefits again and Also need to check patient’s document in software for any new insurance info. Based on that Bill the patient or resubmit the claim to the correct payer.  

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