Background: The service code submitted on the claim cannot be billed unless a corresponding primary code is billed on the same date by the same attending provider. For example, 90785 can be billed with a 90853 code for the same date of service but cannot be billed alone.

What causes this denial? This denial directly correlates with the NCCI Edits implemented by the Centers for Medicare & Medicaid Services (CMS). For more information on how AlphaMCS handles these edits, refer to the NCCI Edits document under the "General" sub-heading on the AlphaMCS University. For specific details on the NCCI Edits, visit the CMS website.

How do I correct the denial? Contact your claims specialist for further assistance.

The weekly AlphaMCS checkwrite schedule has changed for calendar year 2016. Beginning with January payments, EFT deposits will be made on Wednesdays instead of Tuesdays. All N.C. LME/MCOs have approved and implemented this schedule.

Third-party payers, including Medicare and private health insurance carriers, must process the claim before Smoky does. Providers must report any payments or denial reasons from third-party payers on claims filed with Smoky. Claims submitted without third-party information will be denied.

Smoky pays COB claims according to the "lesser of" methodology. If the Medicaid allowed amount is more than the third-party payment, Smoky will pay the difference up to the contracted allowed amount or the patient amount, whichever is less. If the other insurance payment is greater than the Smoky contracted amount, no additional amount will be paid.

Smoky will not pay for any service that could have been paid for by Medicare or other private insurance plans had the beneficiary or provider complied with the plan's requirements. Examples of common private plan non-compliance denials include, but are not limited to: 

• Failure to get an authorization referral from a primary care physician
• Non-participating provider 
• Failure to obtain prior approval

Smoky will not reimburse providers for covered services provided by clinicians who are non-paneled or enrolled under the recipient's third-party coverage plans. If the provider does not have enrolled providers or paneled staff with the primary payer, the consumer should be referred to an eligible provider of third-party covered services. First-party payers are the clients or their guarantors. State-funded consumers are subject to a co-payment amount depending on their income in accordance with the Smoky Graduated Fee Schedule.