Medical Billing Facts

Medical Billing Fact: Insurance carriers spend in excess of $19 billion annually processing paper claims.

Fact: Healthcare providers spend more than $7 billion annually just submitting claims to carriers.


Fact: According to the New England Journal of Medicine, the U.S. Healthcare System wastes up to 24 cents out of every dollar on administrative and billing costs, or in excess of $6 billion annually.


Fact: 30 to 35% of all paper claims are rejected due to typo's, errors and omissions.


Fact: Less than 1% of electronic claims are rejected.

 

Medical billing fact An electronic claim takes just seconds to prepare.

Fact: Most electronic claims are processed for payment by carriers within 24 hours.



Fact: Electronic claims cost healthcare providers between $1.50 and $3.00 depending on volume, specialty and other factors.

Fact: Using paper claims submission, reimbursement takes an average of 90 to 120 days.

Fact: Electronic claims are paid within 7-21 days.


Fact: Reports show that the average healthcare provider has more than $150,000 in outstanding accounts receivables.


Fact: Electronic Claims Submission can reduce outstanding accounts receivables by more than 60%.


Fact: Coding errors for surgical procedures eats up about $6 billion annually in unneeded costs.


Fact: Medicare provides healthcare coverage to some 35 million people over age 65.


Fact: The social Security Administration estimated some 2.2 million people turned 65 in the year 2003.


Fact: That number will rise to 4.2 million in the year 2027. In all, 74.9 million people will turn 65 during the next 25 year period, creating a future of opportunity.

Read more »

What is ClearingHouse ?

In Medical billing Clearinghouses are a major part of a billing service's ability to conduct business. Your professionalism and reputation depend on aligning yourself with a reputable clearinghouse.


What exactly does a clearinghouse do? Well, for one thing, they check claims for accuracy. But, the biggest thing they do is re-format the data you send to them to a format that a given carrier can read.


Clearinghouses charge fees in many ways. Some charge an initial start up fee to the billing service ranging from $125 to $300. Others are free to sign-up with initially. Some charge a provider enrollment fee for every healthcare provider you enroll, while others don't. Most of them charge a per claim fee of some sort, depending upon the carrier.


In the last couple of years, clearinghouses have adjusted their fees to the advantage of billing services. Many only charge for Medicare, Medicaid and Blue Cross/Blue Shield claims, while major commercial carrier claims are free in some cases.


If the company you are considering purchasing from is not able to offer you free NEIC claims, you may be able to find a better alternative by obtaining your own claims clearinghouse connection.


If a company tells you they are their own clearinghouse, BEWARE!!! That means you are tied into them, and can't use any other clearinghouse. What happens to you if they go out of business? You'll have to buy new software so you can make your own connection with a different clearinghouse.


These days, you can find a company that offers you many choices in clearinghouses. You may need two or more for medical claims and another for dental claims. The point is, be sure your options are many, not few.

Read more »

Useful provider related links

Useful Websites

http://www.upinregistry.com/provider_form.asp

Provider UPIN search Engine



http://www.cms.hhs.gov/NationalProvIdentStand/01_overview.asp

NPI Application online




http://upin.ecare.com/

UPIN numbers are required for insurance billing specifically for referral based practices.
This UPIN Number corresponds with the referring provider.



http://www.healthlink.com/tech_tip_taxonomy_code.asp

Need to know your Taxonomy code? Look it up here!



http://www.upinregistry.com/provider_form.asp

Register your UPIN number and begin the search engine for other provider to access your UPIN number.



http://www.insurance.wa.gov/

Need to contact the Washington State Insurance Commissioner?



http://www.appeallettersonline.com/

Online resource to assist your office in overturning denials, motivating insurers to pay more quickly and preventing denials.

Read more »

The Glossary of Insurance and Medical Billing Terms

ICD-9

A 3 to 5-digit number code describing a diagnosis or medical procedure.
Inpatient A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.

In-Network Provider

Physicians and other service providers who are contracted with a managed care plan.

Out-of-Network Provider

Physicians who are not contracted with a managed care plan.

Outpatient

A patient who receives health care services, but is not admitted to a hospital during a 24-hour period.

Primary Care Physician

A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.

Provider

A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.

Pre-Certification

Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.

Referral Authorization

Approval for a member to see a physician or access services outside of the participating medical group.

Referral Physician

A physician who sees a patient after another doctor has sent them for specialty care or services.

Referring Physician

A physician who sends a patient to another doctor for specialty care or services.

Subscriber

A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.

Treating Physician

A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

Read more »

UNITED STATES AND ITS CODES

Alabama AL
Alaska AK
American Samoa AS
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Federated States of Micronesia FM
Florida FL
Georgia GA
Guam GU
Hawaii HI
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas KS
Kentucky KY
Louisiana LA
Maine ME
Marshall Islands MH
Maryland MD
Massachusetts MA
Michigan MI
Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
New Mexico NM
New York NY
North Carolina NC
North Dakota ND
Northern Mariana Islands MP
Ohio OH
Oklahoma OK
Oregon OR
Palau PW
Pennsylvania PA
Puerto Rico PR
Rhode Island RI
South Carolina SC
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virgin Islands VI
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
Wyoming WY
Armed Forces Africa AE
Armed Forces Americas AA
Armed Forces Canada AE
Armed Forces Europe AE
Armed Forces Middle East AE
Armed Forces Pacific AP

Read more »

Glossary - Payments

In Medical billing payment related terms are very important for follow up with insurances.

Payments

• Deductible
• Explanation of Benefits (EOB)
• Bundled Payment
• Transaction Control Number (TCN)
• Rejection & Reviews
• Out of Pocket Expenses

Deductible:

The amount of expense an insured must first incur before insurance begins payment for covered services.

Explanation of Benefits (EOB)

After an insurance carrier processed a claim, and the claim is paid, a document known as an Explanation of Benefits is usually issued to the Provider who receives along with a payment check and to the Insured, if the benefits have been assigned. If the claim has not been assigned, payment goes to the patient and the physician may have a difficult time obtaining this payment
In General EOB is also called as

Statement of Benefits
Notice of Payment

EOB is called with different names by different Insurances

Medicare Remittance Advice (Medicare)
Provider Payment Advisory (Blue Shield)
Medex Detailed Advisory (Medex)
Statement of Account (Tufts)
Practitioner Remittance Advice (Medicaid while Primary)
Practitioner Crossover Remittance Advice (Medicaid secondary)
Explanation of Payment (Pilgrim Health)

Bundled Payment:

A single comprehensive payment for a group of related services.
For example,
94760 (NONINVASIVE PULSE OXIMETRY,SINGLE DETERMINATION)94761 (NONINVASIVE PULSE OXIMETRY, MULTIPLE)
In this case, if both the procedures are billed, insurance will pay for 94762 and will deny both 94760 & 94761 as already included in 94762

Transaction Control Number (TCN)

It is a number automated by the system while automatic crossover. If a claim is resubmitted then we need to provide the old TCN and the insurance will again provide a new TCN for the resubmitted claim. Normally, it has to be resubmitted within 2 weeks.

Rejection/Reviews:

Basically, when a claim is submitted, there may be two types of response from the insurance.

a.Denial
b.Payment

Under Denial, it is categorized as Rejections and Reviews only for the purpose of billing office for further follow up.

Rejection:

When an insurance company denies a claim stating that info provided in the claim is not sufficient to process the claim, for which the patient or guarantor is responsible (which can be collected only from them) is called the “Rejection by Insurance”. Eg. Incorrect Ins ID#, Wrong Ins, etc.

Review:

When an insurance company denies a claim stating that it needs additional info for processing, which can be obtained from the Provider’s or billing office can be defined as “Review”. Wrong Procedure or Diag Code, Invalid or Incomplete info on claim etc are some of the examples for review.

Out of Pocket Expense:

Out of Pocket Expense normally refers to the payment made by the insured.
Normally it refers to Both copay and Deductibles.

Read more »

Medicare Plan or Part D

Its a program for Prescription drugs. Its not like Part A or Part B. Patient has to pay their own premum to buy this services. Its run by private companies.

All plans will have different costs and benefits from year to year, thus it is advisable for all beneficiaries to consider their options and make the best choice they can.

Coverage and Deductible

The Medicare law establishes a standard Part D drug benefit. Plans must offer a benefit package that is at least as valuable as the standard benefit. The standard benefit is defined in terms of the benefit structure, not the particular drugs that must be covered. In 2009, this standard benefit includes an initial $295 deductible. After meeting the

deductible the beneficiaries pay 25% of the cost of covered Part D prescription drugs, up to an initial coverage limit of $2,700. Once the initial coverage limit is reached, beneficiaries are subject to another deductible, known as the "Donut Hole," or "Coverage Gap," in which they must pay the full costs of drugs.

Covered Drugs.

The MMA defines the drugs that are covered under Part D, and therefore the drugs for which payment will be made under Part D, in relationship to their coverage under Medicaid and under other parts of Medicare. A Part D drug is a drug that is approved by the Food and Drug Administration, for which a prescription is required, and for which payment is required under Medicaid.[6] Biological products, including insulin and insulin supplies, and smoking cessation drugs are also covered under Part D.[7]

Read more »

Medicare

Know about Medicare

• Medicare EOB
• Payment Floor
• Waiver of Liability
• Crossover
• Freelook (Medigap)
• Development letter

Medicare EOB:

Medicare used to mail Remittance Advice (RA) to providers and the patient receives a Beneficiary RA. RA has been replaced by Medicare Remittance Advice also called the Medicare Summary Notice. Electronic Claim sending offices receive Electronic Remittance Advice (ERA), The ERA post payments automatically

Payment Floor:

The timeframe established for carrier payment Of Medicare Part B claims. As of October 1,1993, electronically submitted claims will be paid 14 days after the date of receipt, while paper claims will be paid 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing), whether electronic or paper, must be processed within 30 days of receipt or the carrier will be required to pay interest in addition to allowances for covered services

ABN(Advance Beneficiary Notice) (Waiver of Liability):

A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Crossover:

A situation whereby gaps in coverage for the medical expenses for a Medicare Beneficiary are forwarded by the Medicare contractor to the Patient’s medigap insurer for payment. Medigap crossovers occur only if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating Medicare provider. Crossover takes place only in case of Medicare, Medicaid and Medigap Plans.

Free look (Medigap):

A period of time (usually 30 days) when you can try out a Medigap policy. During this time, if you change your mind about keeping the policy, it can be cancelled. If you cancel, you will get your money back.

Development Letter:

A notice from Medicare that a claim submitted by a provider organization cannot be processed without additional information/documentation. The letter identifies the additional information needed and the date by which the information must be received by Medicare .

Read more »

Glossary (A-C)

What is ABN(Advance Beneficiary Notice) (Waiver of Liability)

A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary Notice

Assignment of insurance benefits

An authorization granted by the patient to allow the insurance company to pay claim benefits directly to the provider of care. It is to the provider's benefit to have the patient sign the "assignment of benefits" statement on each claim form. All benefits due to the provider will be mailed directly to the provider rather than to the patient.

Attending physician

The physician in charge of the patient's care; this physician may or may not be the physician who admitted the patient to the hospital.

Capitation

A reimbursement system used by HMOs and some other managed care plans to pay the health care provider a fixed fee on a per capita basis that has no relationship to type of services performed or the number of services each patient receives.

Catastrophic Limit

For services with co-payments or coinsurance, this is the maximum amount out-of-pocket charges you have to pay in a calendar year. Separate limits are usually applied on a per person and per family basis.

Clearing House

It is also referred to as Third Party Administration (TPA). It is an entity that receives, sorts, transmit, edit claims and send each one to correct insurance payer.

Coordination of benefits (COB)

A clause written into an insurance policy or stipulated by state law that requires insurance companies to coordinate the reimbursement of benefits when a policyholder has two or more medical insurance policies. The benefits from the combined policies may pay up to, but may not exceed, 100 percent of the covered benefits of the combined policies for all medical expenses submitted.

Crossover

Medigap crossovers occur only if correct Medigap information is completed on the Medicare claim form and if the patient has previously signed a Medigap crossover authorization form through a participating Medicare provider.

Read more »

Glossary D-M

What is Durable Medical Equipment

Equipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs, hospital beds, and other items that the insurance company determines are medically necessary, in accordance with Medicare laws, regulations and guidelines.


E Codes:


E Codes are supplementary classification of coding in which you look for external causes of injury rather than disease. The use of an E code after the primary or secondary diagnosis tells the insurance carrier what caused the injury.

V Codes:


V codes are used when a person who is not currently sick encounters health services for some specific purpose, such as to act as a donor of an organ, receive vaccination, seek consultation regarding family planning, allergies etc.,

•V codes are also a supplementary classification of coding.


End-stage renal disease (ESRD)

A chronic kidney disorder that requires long-term hemo dialysis or kidney transplantation because the patient's filtration system in the kidneys has been destroyed. Workers who have paid into the Social Security/ Medicare Fund and their dependents with ESRD who meet specific ESRD requirements are covered by Medicare.


Fee-for-service (a medical office bookkeeping and insurance term):

A method whereby the physician or other health care provider bills for each visit or service rendered rather than on an all-inclusive or prepaid fee basis.


Gatekeeper

Primary physician or other health care professional assigned by the insurer to review the medical management of plan enrollees.


Global fee

The fee for total care of a surgical case including all pre/postoperative care. This applies to surgical cases listed in the CPT code book which do not have an asterisk (*) at the end of the code number.

Global surgery:

A Medicare billing term that requires an all-inclusive fee for the following services: preoperative services performed by the surgeon within 24 hours of surgery, all interoperative procedures, treatment of surgical complications not requiring a return to the operating room, and 90 days of surgery related postoperative care.


Home healthcare


If a patient is confined to his/her home and requires skilled care for an illness or injury, Medicare can pay for care provided by a home health agency. Your physician should provide the home health agency with a plan of treatment. The services may be provided either on part-time or intermittent bases, not full time.


Hospice

A hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management, and supportive services to terminally ill people and their families.

Medical Necessity Denials.

In simple terms is whenever a carrier determines that the service rendered was not necessary, or unreasonable. They feel that this particular service was not needed since it comprises as being part of the major procedure.


Two Ways to Deny Services as Medically Unnecessary.

For example, John sees Dr. Humphries because she has a sore throat. Dr.Humphries looks at her throat and ears, takes a throat culture, tells her to get some rest and prescribes an antibiotic. Dr.Humphries spends quite a bit of time talking with the lonely patient and therefore charges for a Level 4 office visit. The carrier subsequently reduces the visit level to a Level2 and pays based on the level2 office visit, because a level 4 visit (according to the definitions in CPT) was not reasonable or necessary to diagnose and treat a sore throat. This is termed a medical necessity reduction.


Medicare

A federal health insurance program for people 65 years of age or over and retired on Social Security, Railroad Retirement, or federal government retirement programs, individuals who have been legally disabled for more than 2 years, and persons with end-stage renal disease.

Medicare Fee Schedule (MFS)

Schedule of Medicare fees based on RBRVS factors. Non PARs are restricted to the limiting fees on this schedule.

Medicare/Medicaid Crossover Program (MCD

A combination of the Medicare and Medicaid/MediCal Programs that is available to Medicare-eligible persons with income below the federal poverty level.

*Medicare Part A: Benefits covering inpatient hospital and skilled nursing facility services, hospice care, home health care, and blood transfusions.

*Medicare Part B: Benefits covering outpatient hospital and health care provider services.

Read more »

W9 Form Download

Hi Friends,

Click the following link to download W9 form.


http://rapidshare.com/files/93592292/fw9.pdf.html

Read more »

Glossary N - P

What is Non-Participating.

In this scenario then the AR needs to identify if out-of-network benefits would be given to a particular patient under this Insurance in some cases the Insurance does not pay for out of network benefits, whereas in other instances there is a penalty of low reimbursement rate, and a slower processing time. Therefore these considerations need to be looked at critically in order to effectively coordinate the collection level.

What is NPI?

The National Provider Identifier (NPI) is another key initiative, which will help in the prevention of fraud and abuse.

NPI is an industry wide unique identifier for providers and suppliers created under the authority of the Health Insurance Portability and Accountability Act of 1996.

CMS developed the NPI effective from 1st Jan 1997.

The NPI is a single block of 10 characters.

The one and only advantage of a NPI over PIN numbers are they are unique for all health plans. NPI are used in the administrative and financial transactions specified by HIPAA

Primary care physician

A Physician who is a member of a Medical group. In which the member has selected to provide health care service. A primary care physician is responsible for authorizing, coordinating and controlling the delivery of covered services to the member. He is also called as Gate Keeper.

Provider Identification Number

PIN is the individual provider number issued by the local Medicare carriers. This number helps the provider in receiving the reimbursement for claims filed to Medicare carrier. The format of PIN is unique and varies from carrier to carrier. If this number is not indicated on all Medicare carrier claims (paper/electronic) will result in a denial as “Unprocessable Claims”.

Unique Physician Identification Number

UPIN is a six digit numeric / alphanumeric number allotted to all Medicare Providers. UPIN is issued by HCFA. A UPIN is required if the service is requested by a referring physician or an ordering physician.

Pre-Admission Certification:

Before being admitted as inpatient in a hospital certain criteria are used to determine whether the inpatient care is necessary.


Pre-authorization:

Is when the Insurance needs to be contacted prior to rendering of any medical service. Some type of treatments which are of big dollar value for example Radiation Therapy (for cancer treatment) would be very expensive, therefore the carrier would request the doctors office to obtain previous approval from their Utilization Management department before treating any patient, in this way they could track their expenditure as well as keep track on all big dollar accounts. If the doctor's office fails to get this authorization then the claim would be denied.

Under Managed Care we have HMO's, PPO's, EPO's.


Pre-Existing Condition:

A health problem that existed or was treated before the date your insurance became effective. Most health insurance contracts have a pre existing condition clause that describes under what condition they will cover medical expense related to a pre-existing condition.


Provider Enrollment Forms

These forms would be given by the carrier which needs to be filled in correctly so that the Insurance could then update their records of who is the doctor/Provider his UPIN number his mailing address the location of his facility, and is he/she treating in more than one facility. All these details would be fed into their system to maintain accurate records.

Read more »

NPI Application and Updation form

Hi you can download a NPI Application and updation form

Click the following link to DOWNLOAD


http://rapidshare.com/files/95266645/NPI_Application_and_update_form.pdf.html

Read more »

Medicare coverage - Physician Expense for Surgery, Childbirth, and Treatment for Infertility

Surgery and Childbirth


Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care. Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e., where the life of the mother would be endangered if the fetus were brought to term), the need for skilled medical management and/or medical services is equally important as in those cases carried to full term. After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mother’s eligibility.

Most surgeons and obstetricians bill patients an all-inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child. All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and post-operative/postnatal services, are considered incurred on the date of surgery or delivery, as appropriate. This policy applies whether the physician bills on a package charge basis, or itemizes the bill separately for these items.

Occasionally, a physician’s bill may include charges for additional services not directly related to the surgical procedure or the delivery. Such charges are considered incurred on the date the additional services are furnished.

The above policy applies only where the charges are imposed by one physician or by a clinic on behalf of a group of physicians. Where more than one physician imposes charges for surgical or obstetrical services, all preoperative/prenatal and post-operative/postnatal services performed by the physician who performed the surgery or delivery are considered incurred on the date of the surgery or delivery. Expenses for services rendered by other physicians are considered incurred on the date they were performed.



Treatment for Infertility
Reasonable and necessary services associated with treatment for infertility are covered under Medicare. Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally is expected to be fertile to seek medical consultation and treatment.

Read more »

Reasons for Claims Denial

In addition to pended claims, claims processing may also result in the denial or rejection of claims. These claims may very well have come in as clean claims; however, some reason has been determined for the nonpayment of the claim. On average, 14 percent of claims received were denied for payment.
 

Almost half of all claim denials (48 percent) were due to the submission of a duplicate claim. Some plans indicated that though a claim may have been initially submitted electronically, there often is a paper claim received that unnecessarily follows up to confirm the submission.
 

A claim for a noncovered benefit, or for an individual who is no longer covered or whose policy has lapsed, each represented about 20 percent of rejected claims.

1. Non covered benefit
2. Eligibility issues
3. Coverage termination/
4. premium lapse
5. Duplicate claim
6. Other

Read more »

Why clean claims are best ?

Proportion of “Clean” Claims

The vast majority of claims received, whether electronically or on paper, are “clean” and do not present problems with missing information or format errors. Claims received electronically have some advantage over paper claims across all provider categories surveyed. On average about 94 percent of claims received electronically are clean versus 86 percent of paper claims. Physicians
do slightly better on their percentage of clean claims than do hospitals (97 percent versus 94 percent for electronic claims and 89 percent versus 87 percent for paper), and both do better than other health care providers.

Automatic Adjudication of Claims

 
Electronically submitted claims have a large advantage over paper in the automatic adjudication of claims (claims processed without human involvement once they are entered into the processing system). There is almost a two-to-one margin in the percentage of electronic versus paper claims that are so adjudicated (49 percent versus 27 percent respectively). Automatic adjudication of claims allows for quicker processing times and less costly processing than manual intervention resulting in savings to the
health plan, providers, and ultimately consumers.

Read more »

What Is an Appeal? and how to appeal the denial?

What Is an Appeal?

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan.

You can appeal if Medicare or your plan denies one of the following:

A request for a health care service, supply, or prescription that
You think you should be able to get
A request for payment for health care services or supplies or a
Prescription drug you already got that was denied
A request to change the amount you must pay for a prescription  drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

If you decide to file an appeal, ask your doctor or other health care provider or supplier for any information that may help your case.

How to File an Appeal

How you file an appeal depends on the type of Medicare coverage you have:

If you have a Medicare health plan, look at your plan materials, call your plan, or visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet, “Your Medicare Rights and Protections.”

If you have a Medicare Prescription Drug Plan, look at your plan materials, ■■call your plan, or look on pages 90–91 to learn how to file an appeal.

If you have Original Medicare, do the following to file an appeal:

Get the Medicare Summary Notice (MSN) that shows the item or  service you are appealing. Your MSN is the statement you get every 3 months that lists all the services billed to Medicare and tells you if Medicare paid for the services.

Circle the item(s) you disagree with on the MSN, and write an explanation on the MSN of why you disagree.Sign, write your telephone number, and provide your Medicare number on the MSN. Keep a copy for your records.

Send the MSN, or a copy, to the Medicare contractor’s address listed 4. on the MSN. You can also send any additional information you may have about your appeal.

You must file the appeal within 120 days of the date you get the MSN. If you want to file an appeal, make sure you read your MSN carefully, and follow the instructions. You can also use CMS Form 20027, and file it with the Medicare contractor at the address listed on the MSN. To view or print this form, visit
www.cms.hhs.gov/cmsforms/downloads/CMS20027.pdf.

Read more »

Medicare Top ten Claim denials and how to resolve insurance denial?

Top 10 Claim Denials
What should you do when you get a denial?

• Do you file a new claim?
• Request an appeal?
• Top denials will be discussed
      o Denial codes and descriptions
      o Reason denial occurred
      o How to resolve and avoid future denials






1. Denial Code CO - 4


Denial Message
• The procedure code is inconsistent with the modifier used, or a required modifier is missing (04)
 
Reason for Denial
• Claim was filed with a procedure code and modifier that did not correspond.


How to resolve and avoid future denials
 
• Verify that the procedure code and modifier descriptions correspond with each other
• File claims with consistent procedure code and modifier descriptions
• Access the Modifier Lookup tool on www.PalmettoGBA.com/bsc homepage


2. Denial Code CO -125, MA120


Denial message
• Payment adjusted due to billing or submission error (125)
• Missing/incomplete/invalid CLIA certification number (120)

Reason for denial
 
• Claim contains incomplete/or invalid CLIA certification number

How to resolve and avoid future denials
 
• Resubmit the claim using the appropriate CLIA number in Item 23 of the CMS 1500 claim form or in Loop 2300 or 2400, REF/X4, 02 for electronic claims
• Updates to the waived test under CLIA are published in the Medicare Advisory
• A complete list of tests granted waived status under CLIA is attached to CR 5913 at www.cms.hhs.gov/Transmittals/downloads/ R1477CP.pdf.


3.Denial Code CO - 16, MA83


Denial message
 
• Claim/service lacks information which is needed for adjudication (16)
• Did not indicate whether Medicare is primary or secondary payer (83)
 
Reason for denial
 
• The MSP type was not submitted in the 2000B, SBR, 05 (Insurance Type Code) field


How to resolve the denial
 
• Resubmit the claim with the appropriate MSP type in the Insurance Type Code field
• For a complete list of MSP types www.PalmettoGBA.com/bsc/resources
    o Select Medicare Secondary Payer
   o Electronic Claims – Valid MSP Types




4. Denial Code CO - 16, N290


Denial Message
 
•  Claim/service lacks information which is needed for adjudication (16)
•  Missing/incomplete/invalid rendering provider identifier (290)
 
Reason for denial 
• The claim was filed with an invalid or missing rendering NPI


How to resolve and avoid future denials
 
• Refile the claim with the valid rendering provider’s NPI in Item 24J of the CMS 1500 claim  form
•  For assistance with obtaining NPIs
   o NPI Registry
   • https://nppes.cms.hhs.gov




5. Denial Code CO - 16, N257


Denial message
 
•  Claim/service lacks information which is needed for adjudication (16)
•  Missing/incomplete/invalid billing provider primary identifier (257)
 
Reason for denial• The claim was filed with an invalid or missing NPI


How to resolve and avoid future denials
 
•  File claims with the valid billing provider NPI
•  Verify the appropriate billing provider NPI is listed in Item 33 of CMS 1500 claim form
•  Billing for group – use group NPI
•  Solo practitioner – use individual NPI





6. Denial Code CO - 5


Denial message
• The procedure code/bill is inconsistent with the place of service (05)
 
Reason for the denial• Service was rendered at a facility/location that was inappropriate or invalid


How to resolve and avoid future denials
• Verify that the procedure code/bill is consistent with the place of service
• Resubmit as a new claim with a procedure code consistent with the place of service



7. Denial Code CO -140, MA61


Denial message
• Patient/insured health identification number and name do not match (140)
• Missing/incomplete/invalid social security number or health insurance claim number (61)
 
Reason for denial• Claim was filed for a patient whose Medicare number does not match the SSA records and CWF


How to resolve and avoid future denials
 
• Review the patient’s file to locate a copy of the Medicare card. If copy has not be obtained:
   o Contact the patient for the information
   o Call the referring/ordering physician to obtain the information
• File a new claim with the correct name and Health Insurance Claim Number (HIC) as listed on the Medicare card




8. Denial Code CO - 96, M117


Denial message
• Non-covered charge(s) (96)
• Not covered unless submitted via electronic claim (117)
 
Reason for denial• Claims were received in hard copy format


How to resolve and avoid future denials
 
• Submit claims electronically in the HIPAA complaint 837 format
•  If you must submit hard copy claims, contact EDI Technology Support Center to appeal your filing status
•  EDI Technology Support – 1-866-749- 4301




9. Denial Code CO - 16, N286


Denial message
• Claim/service lacks information which is needed of adjudication (16)
• Missing/invalid/incomplete referring provider primary identifier (286)
 
Reason for denial•  Claim was filed with a invalid or missing NPI in Item 17B of CMS 1500 Claim Form


How to resolve and avoid future denials
 
•  Refile the claim with the valid referring provider NPI in Item 17B of the CMS 1500 Claim Form
•  For NPI listing, visit
   o  http://www.nppes.cms.hhs.gov




10. Denial Code Co -16, N234


Denial message
• Claim/service lacks information needed for adjudication (16)
• Missing/incomplete/invalid last seen visit date (234)

Reason for denial
• Claim was not submitted with a 6-digit or 8-digit date patient was last seen by their attending physician




How to resolve and avoid future denials
• Routine foot care
 o Item 19 of CMS 1500 claim form
 
• Include a 6-digit (mm/dd/yy) or an 8-digit (mm/dd/yyyy) date patient was last seen by his/her attending physician
 
• Include the NPI of the patient’s attending physician

Read more »

Medicaid denial reason code list

Medicaid Claim Denial Codes

1  Deductible Amount
2  Coinsurance Amount
3  Co-payment Amount
4  The procedure code is inconsistent with the modifier used or a required modifier is missing.
5  The procedure code/bill type is inconsistent with the place of service.
6  The procedure/revenue code is inconsistent with the patient's age.
7  The procedure/revenue code is inconsistent with the patient's gender.
8  The procedure code is inconsistent with the provider type/specialty (taxonomy).
9  The diagnosis is inconsistent with the patient's age.
10  The diagnosis is inconsistent with the patient's gender.
11 The diagnosis is inconsistent with the procedure.
12 The diagnosis is inconsistent with the provider type.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Payment adjusted because the submitted authorization number is missing, invalid, or
does not apply to the billed services or provider.
 16 Claim/service lacks information which is needed for adjudication. Additional
information is supplied using remittance advice remarks codes whenever appropriate
Note: Changed as of 2/02
17 Payment adjusted because requested information was not provided or was
insufficient/incomplete. Additional information is supplied using the remittance advice
remarks codes whenever appropriate.
Note: Changed as of 2/02
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of the
Worker's Compensation Carrier.
20 Claim denied because this injury/illness is covered by the liability carrier.
21 Claim denied because this injury/illness is the liability of the no-fault carrier.
22 Payment adjusted because this care may be covered by another payer per
coordination of benefits.

23 Payment adjusted due to the impact of prior payer(s) adjudication including payments
and/or adjustments
24 Payment for charges adjusted. Charges are covered under a capitation
agreement/managed care plan.
25 Payment denied. Your Stop loss deductible has not been met.
26 Expenses incurred prior to coverage.
27 Expenses incurred after coverage terminated.
28 Coverage not in effect at the time the service was provided.
Note: Inactive for 004010, since 6/98. Redundant to codes 26&27.
29 The time limit for filing has expired.
30 Payment adjusted because the patient has not met the required eligibility, spend
down, waiting, or residency requirements.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
31 Claim denied as patient cannot be identified as our insured.
32 Our records indicate that this dependent is not an eligible dependent as defined.
33 Claim denied. Insured has no dependent coverage.
34 Claim denied. Insured has no coverage for newborns.
35 Lifetime benefit maximum has been reached.
Note: Changed as of 10/02
36 Balance does not exceed co-payment amount.
Note: Inactive for 003040
37 Balance does not exceed deductible.
Note: Inactive for 003040
38 Services not provided or authorized by designated (network/primary care) providers.
Note: Changed as of 6/03
39 Services denied at the time authorization/pre-certification was requested.
40 Charges do not meet qualifications for emergent/urgent care.
41 Discount agreed to in Preferred Provider contract.
Note: Inactive for 003040
42 Charges exceed our fee schedule or maximum allowable amount.
43 Gramm-Rudman reduction.
44 Prompt-pay discount.
45 Charges exceed your contracted/ legislated fee arrangement.
46 This (these) service(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
47 This (these) diagnosis(es) is (are) not covered, missing, or are invalid.
Note: Changed as of 6/00. This code will be deactivated on 2/1/2006.
48 This (these) procedure(s) is (are) not covered.
Note: Inactive for 004010, since 6/00. Use code 96.
49 These are non-covered services because this is a routine exam or screening procedure
done in conjunction with a routine exam.
50 These are non-covered services because this is not deemed a `medical necessity' by
the payer.
51 These are non-covered services because this is a pre-existing condition
52 The referring/prescribing/rendering provider is not eligible to
refer/prescribe/order/perform the service billed.
Note: Changed as of 10/98. This code will be deactivated on 2/1/2006.
53 Services by an immediate relative or a member of the same household are not
covered.
54 Multiple physicians/assistants are not covered in this case .
55 Claim/service denied because procedure/treatment is deemed
experimental/investigational by the payer.
56 Claim/service denied because procedure/treatment has not been deemed `proven to
be effective' by the payer.
57 Payment denied/reduced because the payer deems the information submitted does not
support this level of service, this many services, this length of service, this dosage, or
this day's supply.
Note: Inactive for 004050. Split into codes 150, 151, 152, 153 and 154.
58 Payment adjusted because treatment was deemed by the payer to have been rendered
in an inappropriate or invalid place of service.
Note: Changed as of 2/01
59 Charges are adjusted based on multiple surgery rules or concurrent anesthesia rules.
Note: Changed as of 6/00
60 Charges for outpatient services with this proximity to inpatient services are not
covered.
61 Charges adjusted as penalty for failure to obtain second surgical opinion.
Note: Changed as of 6/00
62 Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.
Note: Changed as of 2/01
63 Correction to a prior claim.
Note: Inactive for 003040
64 Denial reversed per Medical Review.
Note: Inactive for 003040
65 Procedure code was incorrect. This payment reflects the correct code.
66 Blood Deductible.
67 Lifetime reserve days. (Handled in QTY, QTY01=LA)
Note: Inactive for 003040
68 DRG weight. (Handled in CLP12)
Note: Inactive for 003040
69 Day outlier amount.
70 Cost outlier - Adjustment to compensate for additional costs.
Note: Changed as of 6/01
71 Primary Payer amount.
Note: Deleted as of 6/00. Use code 23.
72 Coinsurance day. (Handled in QTY, QTY01=CD)
Note: Inactive for 003040
73 Administrative days.
Note: Inactive for 003050
74 Indirect Medical Education Adjustment.
75 Direct Medical Education Adjustment.
76 Disproportionate Share Adjustment.
77 Covered days. (Handled in QTY, QTY01=CA)
Note: Inactive for 003040
78 Non-Covered days/Room charge adjustment.
79 Cost Report days. (Handled in MIA15)
Note: Inactive for 003050
80 Outlier days. (Handled in QTY, QTY01=OU)
Note: Inactive for 003050
81 Discharges.
Note: Inactive for 003040
82 PIP days.
Note: Inactive for 003040
83 Total visits.
Note: Inactive for 003040
84 Capital Adjustment. (Handled in MIA)
Note: Inactive for 003050
85 Interest amount.
86 Statutory Adjustment.
Note: Inactive for 004010, since 6/98. Duplicative of code 45.
87 Transfer amount.
88 Adjustment amount represents collection against receivable created in prior
overpayment.
Note: Inactive for 004050.
89 Professional fees removed from charges.
90 Ingredient cost adjustment.
91 Dispensing fee adjustment.
92 Claim Paid in full.
Note: Inactive for 003040
93 No Claim level Adjustments.
Note: Inactive for 004010, since 2/99. In 004010, CAS at the claim level is optional.
94 Processed in Excess of charges.
95 Benefits adjusted. Plan procedures not followed.
Note: Changed as of 6/00
96 Non-covered charge(s).
97 Payment is included in the allowance for another service/procedure.
Note: Changed as of 2/99
98 The hospital must file the Medicare claim for this inpatient non-physician service.
Note: Inactive for 003040
99 Medicare Secondary Payer Adjustment Amount.
Note: Inactive for 003040
100 Payment made to patient/insured/responsible party.
101 Predetermination: anticipated payment upon completion of services or claim
adjudication.
Note: Changed as of 2/99
102 Major Medical Adjustment.
103 Provider promotional discount (e.g., Senior citizen discount).
Note: Changed as of 6/01
104 Managed care withholding.
105 Tax withholding.
106 Patient payment option/election not in effect.
107 Claim/service denied because the related or qualifying claim/service was not
previously paid or identified on this claim.
Note: Changed as of 6/03
108 Payment adjusted because rent/purchase guidelines were not met.
Note: Changed as of 6/02
109 Claim not covered by this payer/contractor. You must send the claim to the correct
payer/contractor.
110 Billing date predates service date.
111 Not covered unless the provider accepts assignment.
112 Payment adjusted as not furnished directly to the patient and/or not documented.
Note: Changed as of 2/01
113 Payment denied because service/procedure was provided outside the United States or
as a result of war.
Note: Changed as of 2/01; Inactive for version 004060. Use Codes 157, 158 or 159.
114 Procedure/product not approved by the Food and Drug Administration.
115 Payment adjusted as procedure postponed or canceled.
Note: Changed as of 2/01
116 Payment denied. The advance indemnification notice signed by the patient did not
comply with requirements.
Note: Changed as of 2/01
117 Payment adjusted because transportation is only covered to the closest facility that
can provide the necessary care.
Note: Changed as of 2/01
118 Charges reduced for ESRD network support.
119 Benefit maximum for this time period or occurrence has been reached.
Note: Changed as of 2/04
120 Patient is covered by a managed care plan.
Note: Inactive for 004030, since 6/99. Use code 24.
121 Indemnification adjustment.
122 Psychiatric reduction.
123 Payer refund due to overpayment.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
124 Payer refund amount - not our patient.
Note: Inactive for 004030, since 6/99. Refer to implementation guide for proper
handling of reversals.
125 Payment adjusted due to a submission/billing error(s). Additional information is
supplied using the remittance advice remarks codes whenever appropriate.
Note: Changed as of 2/02
126 Deductible -- Major Medical
Note: New as of 2/97
127 Coinsurance -- Major Medical
Note: New as of 2/97
128 Newborn's services are covered in the mother's Allowance.
Note: New as of 2/97

Read more »

Medicaid Claim Denial Codes - List 2

Medicaid Claim Denial Codes

129 Payment denied - Prior processing information appears incorrect.
Note: Changed as of 2/01
130 Claim submission fee.
Note: Changed as of 6/01
131 Claim specific negotiated discount.
Note: New as of 2/97
132 Prearranged demonstration project adjustment.
Note: New as of 2/97
133 The disposition of this claim/service is pending further review.
Note: Changed as of 10/99
134 Technical fees removed from charges.
Note: New as of 10/98
135 Claim denied. Interim bills cannot be processed.
Note: New as of 10/98
136 Claim Adjusted. Plan procedures of a prior payer were not followed.
Note: Changed as of 6/00
137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or Health
Related Taxes.
Note: New as of 2/99
138 Claim/service denied. Appeal procedures not followed or time limits not met.
Note: New as of 6/99
139 Contracted funding agreement - Subscriber is employed by the provider of services.
Note: New as of 6/99
140 Patient/Insured health identification number and name do not match.
Note: New as of 6/99
141 Claim adjustment because the claim spans eligible and ineligible periods of coverage.
Note: Changed as of 6/00
142 Claim adjusted by the monthly Medicaid patient liability amount.
Note: New as of 6/00
143 Portion of payment deferred.
Note: New as of 2/01
144 Incentive adjustment, e.g. preferred product/service.
Note: New as of 6/01
145 Premium payment withholding
Note: New as of 6/02
146 Payment denied because the diagnosis was invalid for the date(s) of service reported.
Note: New as of 6/02
147 Provider contracted/negotiated rate expired or not on file.
Note: New as of 6/02
148 Claim/service rejected at this time because information from another provider was not
provided or was insufficient/incomplete.
Note: New as of 6/02
149 Lifetime benefit maximum has been reached for this service/benefit category.
Note: New as of 10/02
150 Payment adjusted because the payer deems the information submitted does not
support this level of service.
Note: New as of 10/02
151 Payment adjusted because the payer deems the information submitted does not
support this many services.
Note: New as of 10/02
152 Payment adjusted because the payer deems the information submitted does not
support this length of service.
Note: New as of 10/02
153 Payment adjusted because the payer deems the information submitted does not
support this dosage.
Note: New as of 10/02
154 Payment adjusted because the payer deems the information submitted does not
support this day's supply.

155 This claim is denied because the patient refused the service/procedure.
Note: New as of 6/03
156 Flexible spending account payments
Note: New as of 9/03
157 Payment denied/reduced because service/procedure was provided as a result of an act
of war.
Note: New as of 9/03
158 Payment denied/reduced because the service/procedure was provided outside of the
United States.
Note: New as of 9/03
159 Payment denied/reduced because the service/procedure was provided as a result of
terrorism.
Note: New as of 9/03
160 Payment denied/reduced because injury/illness was the result of an activity that is a
benefit exclusion.
Note: New as of 9/03
161 Provider performance bonus
Note: New as of 2/04
162 State-mandated Requirement for Property and Casualty, see Claim Payment Remarks
Code for specific explanation.
Note: New as of 2/04
163 Claim/Service adjusted because the attachment referenced on the claim was not
received.
Note: New as of 6/04
164 Claim/Service adjusted because the attachment referenced on the claim was not
received in a timely fashion.
Note: New as of 6/04
165 Payment denied /reduced for absence of, or exceeded referral
Note: New as of 10/04
166 These services were submitted after this payers responsibility for processing claims
under this plan ended.
Note: New as of 2/05
167 This (these) diagnosis(es) is (are) not covered.
Note: New as of 6/05
168 Payment denied as Service(s) have been considered under the patient's medical plan.
Benefits are not available under this dental plan
Note: New as of 6/05
169 Payment adjusted because an alternate benefit has been provided
Note: New as of 6/05
170 Payment is denied when performed/billed by this type of provider.
Note: New as of 6/05
171 Payment is denied when performed/billed by this type of provider in this type of
facility.
Note: New as of 6/05
172 Payment is adjusted when performed/billed by a provider of this specialty
Note: New as of 6/05
173 Payment adjusted because this service was not prescribed by a physician
Note: New as of 6/05
174 Payment denied because this service was not prescribed prior to delivery
Note: New as of 6/05
175 Payment denied because the prescription is incomplete
Note: New as of 6/05
176 Payment denied because the prescription is not current
Note: New as of 6/05
177 Payment denied because the patient has not met the required eligibility requirements
Note: New as of 6/05
178 Payment adjusted because the patient has not met the required spend down requirements.
179 Payment adjusted because the patient has not met the required waiting requirements
Note: New as of 6/05
180 Payment adjusted because the patient has not met the required residency
requirements
Note: New as of 6/05
181 Payment adjusted because this procedure code was invalid on the date of service
Note: New as of 6/05
182 Payment adjusted because the procedure modifier was invalid on the date of service
Note: New as of 6/05. Modified on 8/8/2005
183 The referring provider is not eligible to refer the service billed.
Note: New as of 6/05
184 The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Note: New as of 6/05
185 The rendering provider is not eligible to perform the service billed.
Note: New as of 6/05
186 Payment adjusted since the level of care changed
Note: New as of 6/05
187 Health Savings account payments
Note: New as of 6/05
188 This product/procedure is only covered when used according to FDA recommendations.
Note: New as of 6/05
189 "Not otherwise classified" or "unlisted" procedure code (CPT/HCPCS) was billed when
there is a specific procedure code for this procedure/service
Note: New as of 6/05

Read more »

Medicaid rejection list - 3

Medicaid Claim Denial Codes

A0 Patient refund amount.A1 Claim denied charges.
A2 Contractual adjustment.
Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use another
appropriate specific adjustment code.
A3 Medicare Secondary Payer liability met.
Note: Inactive for 004010, since 6/98.
A4 Medicare Claim PPS Capital Day Outlier Amount.
A5 Medicare Claim PPS Capital Cost Outlier Amount.
A6 Prior hospitalization or 30 day transfer requirement not met.
Note:
A7 Presumptive Payment Adjustment
Note:
A8 Claim denied; ungroupable DRG
B1 Non-covered visits.
Note:
B2 Covered visits.
Note: Inactive for 003040
B3 Covered charges.
Note: Inactive for 003040
B4 Late filing penalty.
B5 Payment adjusted because coverage/program guidelines were not met or were
exceeded.
Note: Changed as of 2/01
B6 This payment is adjusted when performed/billed by this type of provider, by this type
of provider in this type of facility, or by a provider of this specialty.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B7 This provider was not certified/eligible to be paid for this procedure/service on this
date of service.
Note: Changed as of 10/98
B8 Claim/service not covered/reduced because alternative services were available, and should have been utilized.

B9 Services not covered because the patient is enrolled in a Hospice.
B10 Allowed amount has been reduced because a component of the basic procedure/test
was paid. The beneficiary is not liable for more than the charge limit for the basic
procedure/test.
Note:
B11 The claim/service has been transferred to the proper payer/processor for processing.
Claim/service not covered by this payer/processor.
Note:
B12 Services not documented in patients' medical records.
Note:
B13 Previously paid. Payment for this claim/service may have been provided in a previous
payment.
Note:
B14 Payment denied because only one visit or consultation per physician per day is
covered.
Note: Changed as of 2/01
B15 Payment adjusted because this procedure/service is not paid separately.
Note: Changed as of 2/01
B16 Payment adjusted because `New Patient' qualifications were not met.
Note: Changed as of 2/01
B17 Payment adjusted because this service was not prescribed by a physician, not
prescribed prior to delivery, the prescription is incomplete, or the prescription is not
current.
Note: Changed as of 2/01. This code will be deactivated on 2/1/2006.
B18 Payment adjusted because this procedure code and modifier were invalid on the date
of service
Note: Changed as of 2/01, 6/05
B19 Claim/service adjusted because of the finding of a Review Organization.
Note: Inactive for 003070
B20 Payment adjusted because procedure/service was partially or fully furnished by
another provider.
Note: Changed as of 2/01
B21 The charges were reduced because the service/care was partially furnished by another
physician.
Note: Inactive for 003040
B22 This payment is adjusted based on the diagnosis.
Note: Changed as of 2/01
B23 Payment denied because this provider has failed an aspect of a proficiency testing
program.
Note: Changed as of 2/01
D1 Claim/service denied. Level of subluxation is missing or inadequate.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D2 Claim lacks the name, strength, or dosage of the drug furnished.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D3 Claim/service denied because information to indicate if the patient owns the
equipment that requires the part or supply was missing.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D4 Claim/service does not indicate the period of time for which this will be needed.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D5 Claim/service denied. Claim lacks individual lab codes included in the test.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D6 Claim/service denied. Claim did not include patient's medical record for the service.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D7 Claim/service denied. Claim lacks date of patient's most recent physician visit.
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary.
D8 Claim/service denied. Claim lacks indicator that `x-ray is available for review.'
Note: Inactive for 004010, since 2/99. Use code 16 and remark codes if necessary

Read more »

INAPPROPRIATE MODIFIER USAGE denial AND UNPROCESSABLE CLAIMS

A modifier is a two-position alpha or numeric code that is added to the end of a Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) code to clarify the service(s) being billed. Modifiers provide a means by which a service is altered without changing the procedure code. They add more information, such as the anatomical site, to the code. The Multi-Carrier System (MCS), Medicare's claim processing system, denies claims as "unprocessable" for inappropriate modifier use. "Unprocessable" means the claim is missing certain information or the information present is incorrect. Unprocessable claim denials to not have appeal rights, you must correct the claim and resubmit it for a proper initial determination. Your Remittance Advice (RA) identifies unprocessable claims by the Medicare Outpatient Adjudication (MOA) code MA130 in the upper right corner of the claim information. Code MA130 means, "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information." Please note that because no initial determination is made on a claim returned as "unprocessable," the submitter may not ask for a review or appeal. If the use of a procedure code/modifier combination is inappropriate, you will need to make the necessary corrections and resubmit the claim. Please refer to the current versions of CPT and HCPCS coding books for correct reporting of modifiers.

Read more »

Insurance denial - Some basic terms which we need to know

Reason Codes

• Provide information about claim decisions
• Tells why a claim was paid differently than it was billed
• CO, PR

Remark Codes

• Numerical codes that further explain the denial
• Indicate if/what appeal rights apply
• B, M, MOA, and N

CO: Contractual Obligation
• Patient cannot be billed
• Provider filing error
• Provider must correct and file a new claim

PR: Patient Responsibility

• Patient can be billed

What should you do when you get a denial?

• Do you file a new claim?
• Request an appeal?
o How to resolve and avoid future denials

Read more »

How to avoid insurance denial - Best six points to remember.

Insurance claim denials can be costly for any family medicine practice. Denials may lead to one of two different scenarios:

A. If the denial is not applicable, your practice will experience a loss of income for a service already performed; or,

B. You will incur increased expense in appealing the denial — a situation no practice wants to be faced with, particularly as reduced payment from many payers affects practice income.

How to avoid insurance denial 

Here are the important points

1. Verify Insurance Plan Coverage every time: While this may seem obvious, in fact the number of claims denied or returned because the wrong insurance carrier is billed is staggering. It is the number one reason claims are not paid upon first submission.

2. Billing for services found to be “medically not necessary”: This is a second reason claims are commonly denied or not paid. All too often, practices write this money off and do not bill the patient for these services.

You can be proactive in reducing these denials by knowing which of the services you provide are tied to specific diagnoses, time periods (e.g., annually, biannually, every five years) or other payment conditions. Next, implement a policy to address how to bill for these services if one of the conditions is not met.

3. Updating Codes (ICD-9, CPT, HCPCS): Every year the code sets used to report and develop insurance claims are updated. Using invalid codes is a frequent source of claim denial.

4. Obtaining a copy of the member’s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information.

5. If a corrected claim is needed, it must be marked as “corrected claim”, and indicate what is being corrected. If the corrected claim is not marked as such, it may be denied as duplicate or the issue may not be resolved appropriately

6.  Be sure to include all current and complete provider information on the claims, including the current tax identification number and NPI numbers in the correct fields

Read more »