Denial Code 109: Claim/Service Not Covered by This Payer – How to Resolve (Complete Guide)
When working on medical billing denials, Denial Code 109 is one of the most common issues seen in payer calls and claim follow-ups.
This denial typically means:
The claim was submitted to the wrong insurance payer because another insurance is primary.
In simple terms:
The payer is saying “We are not the primary insurance. Send it to the correct payer.”
This blog explains the On-Call scenario flow, the right questions to ask the payer, and the next steps for claim resolution.
What is Denial Code 109?
Denial Code 109 description:
Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Main reason:
• Other payer is primary
• The billed insurance is actually secondary
How to Handle Denial Code 109 (Step-by-Step Call Script)
Step 1: Confirm the Denial
Start the call with:
“Claim denied as other payer is primary.”
Then ask:
Step 2: Ask for Denial Date
“May I get the denial date?”
This is important for tracking TAT and payer timelines.
Step 3: Ask Which Insurance is Primary
“Could you please tell me which insurance is the primary insurance?”
Now there are two possibilities:
Case 1: Rep HAS the Primary Insurance Details
If the rep provides primary insurance info, ask:
Step 4: Confirm Policy Effective and Termed Dates
“What is the effective date and termed date of the policy?”
Step 5: Check if Policy is Active on DOS
DOS = Date of Service
“Was the policy active on DOS?”
If Policy is Active on DOS
Collect complete primary insurance details:
• Policy ID
• Payer ID
• Mailing address
Ask:
“What is the policy ID, payer ID and mailing address of the primary insurance?”
Then request:
“May I have the claim number and call reference number?”
If Policy is NOT Active on DOS
Ask the payer to reprocess since no primary coverage exists:
“Could you please reprocess the claim since there is no active primary insurance?”
Then ask:
“What is the turnaround time (TAT)?”
“May I have the claim number and call reference number?”
Case 2: Rep Does NOT Have Primary Insurance Details
If the rep says they do not have primary insurance info, ask:
“May I have the claim number and call reference number?”
Then internally you must investigate primary insurance details.
Important Note: What to Do If Primary Insurance Info is Missing
If the payer rep cannot provide primary insurance details, you should check:
1. Billing System / Patient Account
• Look for any other insurance listed
• Check patient payment history
• Verify if another insurance was used earlier
2. Eligibility Check for Alternate Insurance
If another insurance is found:
Verify eligibility
Check if active on DOS
Resubmit claim to that payer if active primary
3. Payer Web Portal (If Access Available)
Sometimes primary insurance details can be found in the portal.
Best Practice: Always Verify Eligibility in Portal
Even if payer rep provides primary insurance, always verify eligibility online (if portal access is available).
Reason:
• Primary insurance might appear active, but could be inactive on DOS.
• Portal eligibility is often more reliable.
Final Resolution Steps for Denial Code 109
Once you get correct primary payer details:
If Primary Insurance is Active:
Update insurance order in system:
• Set Primary Insurance = correct payer
• Make current insurance Secondary
Submit claim to primary payer.
If Primary Insurance is Inactive or Not Found:
Release the claim to patient responsibility.
What if Primary Insurance Already Paid?
If primary insurance already paid, follow the:
Primary EOB scenario (Explanation of Benefits)
and proceed with secondary billing accordingly.
