Submitted to Incorrect Program: Jurisdiction Details

Published 01/30/2025

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 
  • 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 billed is a durable medical equipment, prosthetic, orthotic or supply (DMEPOS) item that is under DME Medicare Administrative Contractor (MAC) jurisdiction 
  • The beneficiary is in a Medicare Advantage (MA) plan
     
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Denials
  • 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 Part B MAC 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 jurisdictional DME MACs 

DME POS Jurisdiction List: CMS publishes an annual DMEPOS Jurisdiction List on their website. All HCPCS codes listed are designated as under DME MAC or joint MAC Jurisdiction. 

Codes listed as under DME MAC jurisdiction should be billed to your local DME MAC for patients with Medicare. 

Codes listed as under joint MAC jurisdiction include the criteria of when to bill to the Part B MAC and when to bill to the DME MAC. For example, “Part B MAC if used with implanted DME. If other, other, DME MAC.”

  • If a code is listed as under joint MAC jurisdiction and your claim meets the Part B MAC criteria, the code should be billed to Palmetto GBA 
  • If a code is listed as under joint MAC jurisdiction and your claim does not meet the Part B MAC criteria, the code should be billed to your local DME MAC for patients with Medicare

Any other codes not listed as DME MAC only or dual DME MAC/Part B MAC jurisdiction should be considered to be Part B MAC only jurisdiction and would be billed to Palmetto GBA. 

CMS MAC Website List: Look up the DME contactors for your state/area.

Medicare Advantage (MA) Plan Denials

  • Verify patient eligibility for Medicare Part B prior to submitting claims to Palmetto GBA 
  • The Palmetto GBA eServices portal Eligibility, Plan Coverage tab provides information regarding the beneficiary's enrollment in Medicare Advantage (MA) plans and MA Managed Care Plans (Part C contracts) that provide Part A and B benefits for beneficiaries enrolled under a contract
     

Online Eligibility Verification through eServices

  • CMS offers real-time Internet-based eligibility transactionsthrough our secure, provider portal, eServices. All providers that have an EDI Enrollment Agreement on file with Palmetto GBA may register to use this tool. If you haven’t already registered for eServices, we encourage you to do so today.
  • 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)

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