Medicare Denied Claim: Sent to Wrong Insurance

What This Means

Medicare denied this claim because it was sent to the wrong insurance plan. On your notice this usually appears as CARC code CO-109, “Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor,” or CO-22, “This care may be covered by another payer per coordination of benefits.” This usually means one of two things: either another insurer should have been billed first (because Medicare is your secondary insurance), or the claim was sent to Original Medicare when you’re in a Medicare Advantage plan (or the other way around).

This is a routing problem. Your care may still be fully covered — the claim just needs to go to the right place.

Why This Happens

• You have other insurance that should pay first. If you have coverage through your or your spouse’s current employer (generally employers with 20 or more employees), or a workers’ compensation or auto/no-fault claim that covers the service, that insurer generally pays before Medicare under Medicare’s coordination-of-benefits rules. (Retiree coverage, COBRA, and most small-employer plans pay after Medicare.) If the provider skips the primary insurer and bills Medicare directly, Medicare will deny the claim.
• The claim was sent to Original Medicare but you have a Medicare Advantage plan (or vice versa). Medicare Advantage (Part C) plans handle their own claims. If a provider bills Original Medicare by mistake — or the other way around — the claim will be denied. This is a common mix-up, especially if you recently enrolled in or left a Medicare Advantage plan.
• The provider has outdated insurance information on file. If you changed plans and didn’t update your provider, they may be billing the wrong insurer.
• The secondary claim was submitted without the primary insurer’s decision. When Medicare is your secondary payer, the provider usually needs to include the primary insurer’s Explanation of Benefits (EOB) with the claim.

Should You Appeal?

What To Do Next

1. Contact your provider’s billing office. Let them know the claim was denied because it was sent to the wrong payer. Ask them to resubmit it to the correct insurance plan.
2. Check your insurance cards. Make sure your provider has your current insurance information on file. If you recently changed plans, update them.
3. If you have two types of insurance, make sure your provider knows which one is primary (pays first) and which is secondary. Your Medicare Summary Notice or the Benefits Coordination & Recovery Center (BCRC) can help clarify this.
4. Call 1-800-MEDICARE if Medicare’s records are wrong. If Medicare thinks you have other insurance but you don’t, call 1-800-MEDICARE (1-800-633-4227) to update your records. You can also contact the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.
5. Do not pay a bill for this. A wrong-payer denial is not a coverage denial. The service may still be fully covered once the claim reaches the right insurer.

Sources

• X12: Claim Adjustment Reason Codes — official CARC code definitions
• Medicare.gov: How Medicare Works With Other Insurance
• CMS: Coordination of Benefits & Recovery Overview
• CMS: Coordination of Benefits & Recovery Contacts (BCRC)

Frequently Asked Questions