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Last Modified: 9/2/2018 Location: FL, PR, USVI Business: Part B

Denial reason code CO/PR B7 FAQ

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?
Provider was not certified/eligible to be paid for this procedure/service on this date of service.
A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, the procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.
Submit claims for services rendered on/after the provider’s effective date and prior to the provider’s termination date.
Review the Medicare Remittance Advice (RA), and verify the date of service.
If the date of service is not correct, follow procedures for correcting claim errors.
If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
View enrollment information through the internet-based Provider Enrollment, Chain and Ownership System (PECOS), and confirm provider’s Medicare effective date. Click here external link for more details.

The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.
If you require additional assistance, you may contact Provider Enrollment.
If billing for laboratory services, submit claims within the scope of the provider’s CLIA certification.
Verify service/procedure code is listed as approved under the scope of the provider’s certification.
Refer to the complete list of downloads of Categorization of Tests external link on the Centers for Medicare & Medicaid Services (CMS) website.
Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests). For assistance, you may review the CLIA - CPT codes requiring modifier QW tutorial.
If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line(s) only. Resubmitting the entire claim may result in a duplicate claim denial.
Or, if applicable, you may request a reopening via the:
Secure Provider Online Tool (SPOT). Click here for additional information.
First Coast Service Options Part B interactive voice response (IVR). Click here for additional information.
Source: First Coast Education Action Team
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Source: First Coast Education Action Team
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