Tools and Tips

Whenever you receive a denial from your Durable Medical Equipment Medicare Administrative Contractor (DME MAC) — the organization formerly known as the DMERC (no relation to Prince!) — it will be one of two types of denials, technical or non-technical. To effectively "work" your Medicare denials, you must understand the difference between the two. Here?s how:

Highlights

Every claim that is received and processed for durable medical equipment or supplies is given its own unique identification number. This 14-digit number, referred to on your Explanation of Medicare Benefits (EOMB) as the ICN number, contains a hidden message to help you determine whether you have a technical or non-technical denial. This message is the actual day your claim hit the DME MAC?s processing computer. The date is not necessarily the day you transmitted, and certainly not the day you mailed the claim but the date the DME MAC recorded the claim into the computer system. You must be able to decipher this number to manage your denials properly.

The key digits in the ICN number are the first five. The first two digits represent the year your claim hit the DME MAC processing computer. The next three digits represent the Julian day your claim hit the processing computer. The Julian day is always a three-digit number with January 1 = 001, January 2 = 002, December 31 = 365 (366 in a leap year!). For example, an ICN number of 06065890543854 means the claim was entered into the DME MAC processing computer on the 65th day of 2006 (March 6, 2006).

You will need to be able to decipher this date to determine the type of denial (technical or non-technical) and you must be able to tell the difference between the two. A technical denial is easy to receive if you are billing paper claims where you forgot to include the client's birthday or the physician?s UPIN number. Examples of technical denials on electronic claims would be billing the initial claim for an item requiring a CMN without electronically attaching the CMN, using OTH000 as the UPIN number for a physician when the physician has a legitimate UPIN, or not sending enough digits in the ICD-9 code (you only sent four digits and five were required with a particular diagnosis code). The most common example of a non-technical denial would be a denial for lack of medical necessity.

To determine what kind of denial you have on your hands you must first translate the ICN number to see what day your claim was placed into the DME MAC?s processing computer (from methodology listed in paragraph three). Next, compare that date with the date on top of the EOMB (the date the EOMB was created/printed). If the difference between these two dates is five days or less (and is usually only two or three), you have a technical denial. If the number of days is six or more you have a non-technical denial.

The DME MACs treat these two types of denials completely differently. All evidence of technical denials are dropped from the DME MAC?s processing computer while an electronic "copy" of non-technical denials is held indefinitely. A technical denial should be fixed and resubmitted/retransmitted to the DME MAC. You have an indefinite amount of time to resubmit/retransmit the claim PROVIDED the date of service is still within Medicare?s timely filing guidelines.

A non-technical denial must be put into the appeal process starting with redetermination. Keep in mind that you have only four months (120 days) from the denial date (the EOMB date, not the ICN date) to request redetermination! If you simply try to fix and resubmit/retransmit a non-technical denial, you will receive CO-18 denial every time. Also note that the 120-day time clock starts from the ORIGINAL denial date of the claim, NOT the CO-18 denial date for the duplicate claim(s).

One last tidbit of information: If you receive a denial back from the DME MAC that contains an MA-130 reason code, STOP, do not go through this exercise! An MA-130 reason code is the DME MAC?s way of telling you the claim was denied for a technical reason. You should treat this reason code the way you treat all other technical denials. Fix them and resubmit! Please note, however, that the MA-130 reason code is not used for 100 percent of technical denials. What this means is that if you receive an MA-130 reason code, rest assured you have a technical denial. Not all technical denials, however, are given the MA-130 reason code. So, if you receive a DME MAC denial and do not see the MA-130 reason code, do the math on the dates to see if it?s a technical or non-technical denial and respond accordingly — resubmission or redetermination.


Highlights

  • The 14-digit number, referred to on your Explanation of Medicare Benefits (EOMB) as the ICN number, contains a hidden message to help you determine whether you have a technical or non-technical denial.
  • This message is the actual day your claim hit the DME MAC?s processing computer. (The date the DME MAC recorded the claim into the computer system.)
  • The key digits in the ICN number are the first five. The first two digits represent the year your claim hit the DME MAC processing computer. The next three digits represent the Julian day your claim hit the processing computer.
  • The Julian day is always a three-digit number with January 1 = 001, January 2 = 002, December 31 = 365 (366 in a leap year!).
  • To determine what kind of denial you have on your hands, you must first translate the ICN number to see what day your claim was placed into the DME MAC?s processing computer.
  • Next, compare that date with the date on top of the EOMB (the date the EOMB was created/printed). If the difference between these two dates is five days or less (and is usually only two or three), you have a technical denial.
  • If the number of days is six or more, you have a non-technical denial.

This article originally appeared in the April 2006 issue of HME Business.

About the Authors

W. David Yates, Ph.D., CSP, CHMM, is the Corporate Safety Manager for Bodine Services of the Midwest, a leading industrial maintenance company serving Illinois, Indiana, Iowa, and Kentucky. For further information, call 217-428-4381.

Roger Meiners, Ph.D., is a professor of law and economics at the University of Texas at Arlington. He is a senior associate of the Political Economy Research Center (PERC) in Bozeman, Montana.

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