Submitted to Incorrect Program: 'Jurisdiction' Denials

Denial Reason, Reason/Remark Code(s)

• CO-109: Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
• CO-N104: This claim/service is not payable under our claims jurisdiction area.  You can identify the correct Medicare contractor to process this claim/service through the CMS website at http://www.cms.gov/
• CA-N418: Misrouted claim.  See the payer's claims submission instructions. 

Resolution/Resources
The most common reasons that claims are denied as 'submitted to incorrect program' are:

• The item is a supply, orthotic, or prosthetic or is an item of medical equipment
• The beneficiary is in a Medicare Advantage (MA) plan

• Submit to Palmetto GBA:
  • Most implanted durable medical equipment (DME) and related supplies must be submitted to Palmetto GBA, not to the DME Medicare Administrative Contractor (DME MAC)
  • Many splint and casting procedure codes must also be submitted to Palmetto GBA
  • Some supplies must be submitted to Palmetto GBA. It is important to note that even though these supplies are considered 'carrier jurisdiction' (not DME MAC jurisdiction), many supplies are not reimbursed separately if they are provided 'incident to' a physician’s service
• Submit to the DME MAC:
  • Submit DME claims to CGS Administrators, LLC (CGS) 
  • Most non-implanted DME, orthotics and prosthetics must be submitted to the DME MAC 

MA Plan Denials

• Verify patient eligibility for Medicare Part B prior to submitting claims to Palmetto GBA through the Palmetto GBA eServices portal or Interactive Voice Response unit (IVR) 
• The patient may no longer have Part B, or he/she may have enrolled in an MA plan

Online Eligibility Verification through eServices

• CMS offers real-time Internet-based eligibility transactions as an alternative to the IVR. 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.
• Billing services and clearinghouses should contact their provider clients to gain access to the system
• Specific instructions for accessing beneficiary eligibility information through eServices are available in the eServices User Manual (PDF, 7.79 MB)