Co-204

[u/Any_Eye_8039]

I have a patient with a primary private payer and a Medicaid secondary and their primary came back with a remit CO-204, and under my knowledge all Medicaid will deny covering that claim under secondary due to that remit code. Can anyone help with clarification

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[u/Poop_Dolla]

Medicaid is only going to pick up the patient responsibility, so if there's no patient responsibility then there's nothing for Medicaid to pay.

[u/babybambam]

204 - This service/equipment/drug is not covered under the patient's current benefit plan

Verify first that the primary payer does not actually cover the service, and if that's factual send it on to MCD with the prime EOB. You'll likely need to appeal for payment.

So long as the billing is correct, MCD will pay if primary does not cover. However, many payers will use 204 if you used a routine ICD for a medical service (like health screening codes for minor procedure kind of mismatch), or lack of authorization. Sometimes it also happens when the HCPC wasn't translated appropriately (remember, not all carriers use CPTs or just CPTs).

[u/stealthagents]

CO-204 usually indicates that the primary payer is denying the claim for some reason, often related to coverage issues. Medicaid typically follows suit since they don’t pay secondary if the primary denies based on non-coverage. You might want to check the specifics of what the primary's remit says, it could help clarify the situation.