Claim Not Covered by this Payer

Common Causes for 109

Denials with code 109 typically happen for the following specific reasons:

• Claim submitted to the wrong insurance payer due to outdated or inaccurate patient insurance information.
• Coordination of benefits (COB) error, such as billing the secondary payer before the primary payer has processed the claim.
• Patient was enrolled in a Medicare Advantage plan or HMO, but the claim was sent to Original Medicare or the wrong Medicare Administrative Contractor (MAC).
• Claim submitted outside the payer’s jurisdiction (e.g., billing a MAC that does not cover the beneficiary’s geographic area).
• Duplicate claim submitted to a payer after the correct payer has already processed the service.

How to Prevent 109 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Verify patient insurance eligibility and payer responsibility at every visit using real-time eligibility tools.
• Confirm primary and secondary payer order for patients with multiple insurance policies before claim submission.
• Check Medicare enrollment status and plan type (Original Medicare, Medicare Advantage, HMO) to ensure claims are sent to the correct contractor.
• Use payer jurisdiction lookup tools (e.g., CMS website) to confirm the correct Medicare contractor for the patient’s address.
• Implement a pre-billing audit to ensure claims are routed to the correct payer and that COB rules are followed.

Appeal Letter Template for 109

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 109 - Claim Not Covered by this Payer

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 109: "Claim Not Covered by this Payer".

The claim was denied with CO 109, indicating it was submitted to a payer not responsible for payment. However, upon review, the patient’s insurance coverage and coordination of benefits were accurately assessed at the time of service, and the claim was submitted to the payer identified as primary per the patient’s current insurance information. Documentation confirms the patient was not enrolled in a Medicare Advantage plan or HMO for the date of service, and the claim was filed within the payer’s jurisdiction and timely filing limits. Therefore, the denial appears to be based on an administrative error in payer assignment rather than a clinical or policy exclusion, and the claim should be processed by the correct payer as originally submitted.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]