Denial Reason, Reason/Remark Code(s)
PR-26: Expenses incurred prior to coverage
PR-27: Expenses incurred after coverage terminated
• Claim Adjustment Reason Code (CARC) 26: Expenses incurred prior to coverage.
• Remittance Advice Remark Code (RARC) N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
• Group Code: Contractual Obligation (CO)
NOTE: Outpatient hospitals and beneficiaries that received services in a hospital outpatient setting may receive different message as established by their particular Medicarecontractor processing the claim.)
Resolution/Resources:
Verify patient eligibility prior to submitting claims to Medicare through the Palmetto GBA Online Provider Services (OPS) tool or Interactive Voice Response (IVR) unit.
We have to check the eligibility information through the insurance website or by calling the payer. Once we got the information we have to check the billed Date Of Service, if it prior or after the coverage then we can very well go ahead and bill the patient without any hesitation.
Online Eligibility Verification through eServices
All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
Online Eligibility Verification through OPS
- All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
- Access the introductory article to learn more by clicking on the ‘Introducing Online Provider Services’ graphic on the top of any of our main state Web pages
- One important consideration: only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
- Billing services and clearinghouses should contact their provider clients to gain access to the system
- Specific instructions for accessing beneficiary eligibility information through OPS are available in the OPS User Manual.
Palmetto GBA IVR
- Jurisdiction 1: (866) 931-3903
- Ohio and West Virginia: (877) 567-9232
- South Carolina: (866) 238-9654
