Technical Denial
|
Part of provisional payments and did NOT have Premium HI
|
Medicare Ends
|
Technical Denial
|
HIB158
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
Technical Denial
|
Received Provisional Payments and had Premium HI
|
Medicare continues only if Premium HI is reinstated See HI 00801.164B.3.
|
Technical Denial
|
HIB 174
DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice
|
Technical Denial
|
Extended, Premium HI, ESRD, MQGE, or Aged
|
No impact on Medicare
|
Technical Denial
|
HIB159
DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice
|
Technical Denial
|
No Medicare coverage
|
N/A
|
Technical Denial
|
Do not include Medicare language in Notice
|
“Not Same as or Related” Denial
(Form 833 Item 11 shows code of 28)
|
Part of provisional benefits and did NOT have Premium HI
|
Medicare Ends
|
MIRS Denial
|
HIB158
DI 13050.105E--
Exhibit 6, Sample Title II MIRS Denial Notice
|
“Not Same as or Related” Denial
(Form 833 Item 11 shows code of 28)
|
Extended, ESRD, MQGE or Aged
|
No impact on Medicare
|
MIRS Denial
|
HIB159
DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice
|
“Not Same as or Related” Denial
|
Premium HI
|
Medicare continues only if Premium HI is reinstated See HI 00801.164.3
|
MIRS Denial
|
HIB 174
DI 13050.105H – Exhibit 8, Sample Title II Technical Denial Notice
|
MIRS Denial
|
Part of provisional payments
|
Medicare ends
|
MIRS Denial
|
HIB158
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial
|
Extended Medicare
|
Medicare Ends
|
MIRS Denial
|
HIB167
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial
|
Premium HI
|
Medicare ends
|
MIRS Denial
|
HIB168
DI 13050.105E-
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial
|
ESRD
|
No impact on Medicare
|
MIRS Denial
|
HIB169
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial
|
Aged Medicare
|
No impact on Medicare
|
MIRS Denial
|
HIB172
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial
|
MQGE
|
Medicare Ends
|
MIRS Denial
|
HIB173
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
MIRS Denial or “Same as or Related” Denial
|
No current Medicare coverage
|
N/A
|
MIRS Denial
|
Do not include Medicare language in notice
|
Reconsideration Denial
|
Extended Medicare, Premium HI, ESRD, Aged
|
No impact on Medicare
|
Recon Denial
|
HIB159
DI 13050.105F--
Exhibit 6, Sample Title II MIRS Denial Notice
|
Reconsideration Denial
|
No current Medicare Coverage
|
N/A
|
Recon Denial
|
Do not include Medicare language in notice
|