CMS Pub. 100-04, ch. 18, § 130.6

Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS codes

G0432, G0433, or G0435, submitted without ICD-9/ICD-10 diagnosis codes V73.89/Z11.4, or V73.89/Z11.4 and

V69.8/Z72.89, use the following messages:

Medicare Summary Notice (MSN) 16.10 - Medicare does not pay for this item or service.

“Medicare no paga por este articulo o servicio”

Claim Adjustment Reason Code (CARC) 167- This (these) diagnosis(es) is (are) not covered.

Group Code CO - (Contractual Obligation)

• Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS

codes G0432, G0433, or G0435, over the benefit maximum, use the following denial messages:

MSN 15.22 – The information provided does not support the need for this many services or items in this period of

time so Medicare will not pay for this item or service.

“La informacíón proporcionada no justifica la necesidad de esta cantidad de servicios o articulos en este periodo

de tiempo por lo cual Medicare no pagará por este articulo o servicio.”

CARC 119 – Benefit maximum for this time period or occurrence has been reached.

Group Code CO - (Contractual obligation).

• Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code

G0432, G0433, G0435, G0475 or CPT-80081 for more than three in a pregnancy term, use the following denial

messages:

CARC 119 – Benefit maximum for this time period or occurrence has been reached.

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 www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the

contractor to request a copy of the NCD.

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800 MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the

same line item, both messages will appear on the same MSN.

MSN: 15.22: “The information provided does not support the need for this many services or items in this period of

time so Medicare will not pay for this item or service.

Spanish Version – “La información proporcionada no justifica la necesidad de esta cantidad de servicios o

artículos en este periodo de tiempo por lo cual Medicare no pagará por este artículo o servicio.”

Group Code - CO

• Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code

G0475, if ICD-9/ICD-10 primary diagnosis code V73.89/Z11.4 and one of the following secondary ICD-9/ICD-10

diagnosis codes: V69.2/Z72.51, V69.8/Z72.89, V69.2/Z72.52, or V69.2/Z72.53 are not present and the beneficiary is

less than 15 and greater than 65 years of age, use the following messages:

CARC 6: “The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.”

RARC N129: “Not eligible due to the patient’s age.”

(Part A only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD210.7 were used when we made this decision."

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the

same line item, both messages will appear on the same MSN.

Group Code - CO

• Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code

G0475, G0432, G0433, or G0435 is not submitted with the appropriate, primary ICD-9/ICD-10 diagnosis code

V73.89/Z11.4, , use the following messages:

CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present.

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

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy

of the NCD.”

(Part A Only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the

same line item, both messages will appear on the same MSN.

Group Code - CO

Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code

G0475, billed more than once per annum [at least 11 full months must elapse from the date of the last

screening], use the following messages:

CARC 119: “Benefit maximum for this time period or occurrence has been reached.”

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

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy

of the NCD.”

(Part A Only)MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policy NCD210.7 was used when we made this decision”

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the

same line item, both messages will appear on the same MSN.

Group Code - CO

• Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS G0475

or CPT-80081 if ICD-9/ICD-10 primary diagnosis code V73.89/Z11.4 and one of the following ICD-9/ICD-10

secondary diagnosis codes are not present for pregnant beneficiaries as listed in section 130.5 (c), use the following

denial messages:

CARC 11: The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service payment Information REF), if present.

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

www.cms.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 CO

(Part A Only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An

LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if

you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo

que está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y

enviar información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD,

llame al 1-800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decision.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same

line item, both messages will appear on the same MSN.

• Effective for dates of service on or after April 13, 2015, when denying claims for CPT 80081 when submitted

with one of the following secondary diagnosis codes denoting pregnancy, but the required HIV primary diagnosis

codes listed below is not present:

For ICD-9: V22.0, V22.1, V23.9

For ICD-10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83,Z34,90, Z34.91, Z34.92, Z34.93,

O09.90, O09.91, O09.92, O09.93

Use the following denial messages:

CARC 167 – This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),

if present.

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

www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of

the NCD.”

(Part A Only) MSN 15.19: “Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD

was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think

it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que

está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar

información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-

800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same

line item, both messages will appear on the same MSN.

Group Code – CO

• Effective for dates of service on or after April 13, 2015, when denying claims for HCPCS 80081when the line –

item is submitted with one of the following required HIV primary diagnosis codes:

For ICD-9: V73.89

For ICD-10: Z11.4

And none of the following secondary diagnosis codes denoting pregnancy are present.

For ICD-9: V22.0, V22.1, V23.9

For ICD-10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93,

O09.90, O09.91, O09.92, O09.93

Use the following denial messages,

CARC 11:

This diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment

(loop 2110 Service Payment Information REF), if present.

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

www.cms.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: CO (Contractual Obligation)

(Part A only) MSN 15.19:

“Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.

You can compare your case to the LCD, and send information from your doctor if you think it could change our

decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que

está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar

información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-

800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD 210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD 210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same

line item, both messages will appear on the same MSN.

• Effective for dates of service on or after April 13, 2015, when denying line level claims for G0475, G0432,

G0433, G0435 or the CPT code 80081 is submitted with one of the pregnancy secondary diagnosis codes, but the Sex

Code on the claim indicates ‘Male’, use the following denial messages:

CARC 7: The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Group Code: CO (Contractual Obligation)

(Part A only) MSN 15.19:

“Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.

You can compare your case to the LCD, and send information from your doctor if you think it could change our

decision. Call 1-800-MEDICARE (1-800-+-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que

está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar

información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-

800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD 210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD 210.7 fueron utilizadas cuando se tomó esta decisión.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same

line item, both messages will appear on the same MSN.

• Effective for dates of service on or after April 13, 2015, when denying line-items with POS other than 11 (Office)

or 81 (Independent Lab) for the HIV screenings HCPCS G0475, G0432, G0433 and ‘G0435, use the following denial

messages:

CARC 171 – Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the

835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC N428 - Not covered when performed in certain settings.

Group Code: CO (Contractual Obligation)

MSN 21.25 - This service was denied because Medicare only covers this service in certain settings.

Spanish Version: “El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."

MSN 15.19:

“Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.

You can compare your case to the LCD, and send information from your doctor if you think it could change our

decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of the LCD”.

Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en inglés) le ayudan a decidir a Medicare lo que

está cubierto. Un LCD se usó para su reclamación. Usted puede comparar su caso con la determinación y enviar

información de su médico si piensa que puede cambiar nuestra decisión. Para obtener una copia del LCD, llame al 1-

800-MEDICARE (1-800-633-4227).

MSN 15.20: “The following policies NCD 210.7 were used when we made this decision.”

Spanish Version – “Las siguientes políticas NCD 210.7 fueron utilizadas cuando se tomó esta decisión.”