Remittance Advice Messages (Rev. 1387, 04-07-08)

by  Jared Staheli
June 26th, 2015

If the claim is denied because the beneficiary is under 35 years of age, contractors must use existing ASC X12N 835 claim adjustment reason code/message 6, “The procedure/revenue code is inconsistent with the patient’s age” along with the remark code M37 (at the line item level), “Service is not covered when the patient is under age 35.”

If the claim is denied for a woman 35-39 because she has previously received this examination, contractors must use existing ASC X12N 835 claim adjustment reason code/message 119, “Benefit maximum for this time period or occurrence has been reached” along with the remark code M89 (at the line item level), “Not covered more than once under age 40.”

If the claim is denied for a woman age 40 and above because she has previously received this examination within the past 12 months, contractors must use existing ASC X12N 835 claim adjustment reason code/message 119, “Benefit maximum for this time period or occurrence has been reached” along with remark code M90 (at the line item level), “Not covered more than once in a 12-month period.”

For Intermediaries/A MACs only:

If the claim is denied because the provider that performed the screening is not certified to perform the type of mammography billed (film and/or digital) use existing ASC X12N 835 claim adjustment reason code/message B7, “This provider was not certified/eligible to be paid for this procedure/service on this date of service.”

For Carriers/B MACs only:

For claims submitted by a facility not certified to perform film mammography, use existing reason code 171, “Payment is denied when performed/billed by this type of provider in this type of facility.” along with remark code N110, “This facility is not certified for film mammography.”

For claims submitted by a facility not certified to perform digital mammograms, use existing reason code 171, “This payment is adjusted when performed/billed by this type of provider, by this type of provider in this type of facility, or by a provider of this specialty” along with remark code N92,“This facility is not certified for digital mammography.”

For claims that were submitted without the facility’s FDA-assigned certification number, use existing reason code 16, “Claim/service lacks information which is needed for adjudication” along with remark code MA128 “Missing/incomplete/invalid FDA approval number.”

For claims that were submitted with an invalid facility certification number, use existing reason code 125, “Payment adjusted due to a submission/billing error(s) along with remark code MA128 “Missing/incomplete/invalid FDA approval number.”

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 18