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

Posted in: Denial and action,Top 10 denial