Co-150 and Pr-150 Denial Guide

Hi All,

In this Post we will try to provide you some information about CO-150 and Pr-150 Denial in Medicare.

Though, the subject is vast but yet we tried our best to cover all the possible areas.

The denial usually pertains to Same or Similar/Overutilization, or sometimes to Item Capped out scenarios.

Important thing to keep in mind is the claims with such denial cant be resubmitted. We'll have to file an appeal to prove item's necessity.

First, we need to ascertain the reason for the denial. Usually Medicare deny SOS when the item is billed/paid prior to RUL, either by our or other supplier. The information could be obtained via IVR, over Same/Similar or CMN status option.

In this case, we need to have HCPC code of the item against which our item is being denied, initial and last paid DOS, number of rentals paid, contact info of the provider paid for the services. Next step would be to check documentation in scanning/BT documents/Medforce.

HCPC code of the item (against which our item is being denied) is needed because in case we appeal, and the item's HCPC codes are different, we'll have to prove why the patient is provided with an upgrade/downgrade or documents relating to Patient's medical condition which made him/her to switch to a different model of the item, now.

If the other provider is involved, item ain't been capped and the provider is no longer billing, we need to have pickup ticket from that provider, delivery ticket from our provider and the documents demonstrating Medical necessity for the item rendered. If the billing of the item is within the BIS/BIN window criteria, that is, the last paid date and the date of service with CO-150 is not within 60 or 90 days, we could file Redetermination to start a new capped rental all over again with Medical necessity documents and documents justifying break in billing.

If the documents are not available, we need to check for ABN, which will indicate that our supplier is aware of SOS item on file and thus have ABN signed. In this case usually we recieve denial PR-150 (if the item is billed with GA modifier appended), we just need to roll down the balance to next payer. If we have ABN on file but we received CO-150 because GA modifier was not appended with the claim, we will have to take the claim to redeterminations with signed ABN. Significant thing is that we can't simply resubmit the denied item with GA modifier as CO-150 denials can't be resubmitted.

If non of the above mentioned documents are not available , Medical Necessity documents and ABN, we need to stop the Sales Order if and only if the billing of other item which is in payable status, billed under the same sales order is not affected. Then raise the task to store for requisite documents.

If the billing of the item is within RUL, item being capped and BIS/BIN is not greater then 60 or 90 days. In this case we need to check for the first DOS our supplier billed, if that claim had a partial reversal which means that item is being paid by Medicare and they are allowing payments for the remaining rentals, we just need to adjust off the balance as Item capped else we need to file redetermination request to indicate what happen to the previously rendered equipment viz it was theft, stolen, lost or beyond repair. Again documents could be requested form store if not available.

These are the most common denial reasons for CO-150.

Hope, we will get benefited from this.

In case of any Query or the new scenarios, Please comment.