Medicare denial CO 4, C0 125 , MA 120, CO 16 & MA 83

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

Denial reason code co 125 , MA 120

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.

Medicare denial code co 16 MA 83

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

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Timely Filing denial - Delaware Physicians Care insurance

It is the responsibility of the provider to maintain their account receivables records, and we recommend providers perform reviews and follow up of their account receivables on at least a monthly basis to determine outstanding Delaware Physicians Care, Incorporated (DPCI) claims. DPCI will not be responsible for claims that were not received and the date of service exceeds the timely filing limit of one hundred twenty days (120) from the date of service.

Recognizing that providers may encounter timely filing claim denials from time to time, we maintain a process to coordinate review of all disputed timely filing claim denials brought to our attention by providers.
 

DPCI criteria to initiate a review to override timely filing:
 

Electronic submission

Electronic claim submission (EDI) reports are available from each provider’s claims clearinghouse after each EDI submission. These reports detail the claims that were sent to DPCI and received by DPCI. Provider must submit hard copy or electronic copy of the acceptance report from the provider’s clearinghouse that indicates the claim was accepted by DPCI within
the 120-day timely filing limit to override timely filing denial and pay the claim.

Please confirm that the claim did not appear on your rejection report. If DPCI determines the original claim submission was rejected, the claim denial will be upheld and communicated in writing to the provider.

Paper submission

Provider must submit a screen print from the provider’s billing system or database with documentation that shows the claim was generated and submitted to DPCI within the 120-day timely filing limit.

Documentation should include:

The system printout that indicates somewhere on the printout:

· That the claim was submitted to DPCI
· Name and ID number of the DPCI member
· Date of service
· Date the claim was filed to DPCI
· A copy of the original CMS-1500 or UB-04 claim form that shows the original date of submission

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claim Authorization denial

Authorization or Referral Number Invalid or Missing

A valid authorization number must be included on the claim for all services requiring prior authorization. For all services requiring a referral, a valid referral number should be indicated on the CMS 1500 (HCFA 1500) form in Box #23 or on the UB-04 form in Box #63 or indicated in the appropriate section designated in the HIPAA Implementation Guide for the 837 transaction. A
copy of the referral must be submitted for all claims.

IMPORTANT – Missing or invalid authorization numbers and missing referrals for specialist, health care professionals or non-participating physician claims may result in processing delays or denials.

IMPORTANT – Only services specifically identified in the authorization will be reimbursed.

Claim Information Does Not Match Authorization

Authorized services provided to the member must be reflected on the claim as agreed to during the authorization process. Procedure codes, frequency, amount, and duration of services must exactly match the information in the authorization. If a medical need for a different service is identified, contact Utilization Management to change or update the authorization prior to the
provision of services.

IMPORTANT: Only services specifically authorized will be considered for reimbursement. hospitals, physicians and health care professionals may include a written description of services in addition to the appropriate HCPCS or CPT
codes as an aid in identifying authorized services. Although an authorization number is indicated on the claim, if the services billed do not match the authorization, the claim will be denied.

IMPORTANT – The service provider (i.e., the physician, health care professional or facility) on the claim must match the practitioner of facility authorized for the service. Inconsistencies may result in inaccurate payments or denials.

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Denial of illegible or incomplete claim

Illegible Claim Information

Information on the claim must be legible in order to avoid delays or inaccuracies in processing. Review billing processes to ensure that forms are typed or printed in black ink, that no fields are highlighted (this causes information to darken when scanned or filmed), and that spacing and
alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. Handwritten corrections on previously submitted claims are not accepted and will be returned.

NOTE – Do not highlight any information on the claim form or accompanying documentation. Highlighted information will become illegible when scanned or filmed. 

NOTE – Submitting the original copy of the claim form will assist in assuring claim information is legible.
 

Denial -  Incomplete Forms

All required information as specified within this manual or the appropriate CMS claims form instruction guides must be included on the claim form in order to ensure prompt and accurate processing.

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Physician information missing denial

Physician Name Missing or Invalid

The hospital, physician or health care professional’s name and Horizon NJ Health identification number for that hospital, physician or health care professional must be listed in the appropriate fields on the claim. The name listed must be the hospitals physician or health care professional that performed the service. The name and number must accurately represent the service practitioner or facility’s name and Tax Identification Number (TIN) and must exactly match the information documented in Horizon NJ Health’s records.

IMPORTANT – An individual physician’s or health care professional’s name is required on all claims whether submitted on paper or electronically. Claims without an individual physician’s or health care professional’s name in Box 31 of the CMS 1500 (HCFA 1500) claim form or Boxes 82 to 83 of the UB-04 claim form cannot be processed for payment.

IMPORTANT – The individual service practitioner’s name and number must be indicated on all claims for professional services, including outpatient clinic claims. Using only the group or billing entity name and number will not be
processed for payment by Horizon NJ Health.

Hospital, Physician or Health Care Professional Identification Number Missing or Invalid

All of the appropriate hospital, physician or health care professional identification numbers must be included on the claim. Those numbers include Horizon NJ Health’s assigned individual and group identification numbers and the TIN. Review the CMS 1500 (HCFA 1500) claim form and the
UB-04 claim form required fields documents in this manual for specific placement of these identification numbers. The HIPAA Implementation Guide for the 837 transaction will indicate where this information should be placed on electronic claims.

IMPORTANT – When the physician, facility or other health care professional has more than one Horizon NJ Health identification number, use the number that matches the services submitted on the claim. Imprecise use of
identification numbers may result in rejections, inaccurate payments or denials.

IMPORTANT – All the information submitted on the claim identifying the service practitioner must exactly match the information documented in Horizon NJ Health’s file. Failure to notify Horizon NJ Health of EIN, address or group affiliation changes can result in processing or payment errors.

Signature Missing

The signature of the provider of service must be present on the claim form and must match the service physician or health care professional name and EIN on file with Horizon NJ Health.

IMPORTANT – Claims without the physician or health care professional signature will be rejected. The physician or health care professional is responsible for re-submitting these claims within 180 calendar days from the date of service.

IMPORTANT – Signatures other than the physician’s or supplier’s are not valid for claims submitted to Horizon NJ Health and could cause payment delays, inaccuracies, rejections or denials

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Coordination of Benefits - Denial

Any services provided to a Horizon NJ Health member is reviewed against benefits provided for that same individual under other insurance carriers with whom the member has coverage. Horizon NJ Health, as a managed care program for Medicaid and New Jersey FamilyCare members in New Jersey, is the “payor of last resort” on claims for services provided to members
also covered by Medicare, employee health plans or other third party medical insurance. Payors which are primary to Horizon NJ Health include (but are not limited to):

• Private health insurance including assignable indemnity contracts
• Health Maintenance Organizations (HMOs)
• Public health programs such as Medicare
• Profit and non-profit health plans
• Self insured plans

• No-fault automobile medical insurance
• Liability insurance
• Worker’s compensation
• Other liable third parties

In cases where another insurer, other than Medicare, is deemed responsible for payment, Horizon NJ Health will pay the difference between our maximum allowable expense and the amount paid by the primary insurer provided this amount does not exceed the lowest contractually agreed amount and does not exceed the normal Horizon NJ Health benefits which would
have been payable had no other insurance existed. When you provide services to a member who has any other coverage, bill the member’s primary insurer directly. Make sure that you follow that insurer’s standard claim submission policies and forms.

Upon receipt of payment, submit applicable claims to Horizon NJ Health for payment of deductibles and coinsurance amounts. Horizon NJ Health reimburses after coordination of benefits and only up to the primary contracted rate for the service. The claim, PCP referral and the primary insurer’s Explanation of Benefits (EOBs) must be submitted within 60 days of the
date of the EOB or within 180 days of the dates of service, whichever is later.
When preparing the claim, include a complete record of the original charges and primary (or additional) payor’s payment as well as the amount due from the secondary or subsequent payor. Submit all pages of the primary (or additional) insurer’s EOB to avoid delays in completing
claims due to missing information or coding and message descriptions. This information ensures accurate coordination of benefits. 

With the exception of Medicare, Horizon NJ Health’s same notification policies that are routinely applied and required must be followed for any claims to be considered for payment.

IMPORTANT – All Coordination of Benefit (COB) claims must be submitted with a copy of the EOB from the primary insurer.

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Medicaid denial code M list

Medicaid Denial Codes -10

M134 Performed by a facility/supplier in which the provider has a financial interest. Note: (Modified 6/30/03)
M135 Missing/incomplete/invalid plan of treatment. Note: (Modified 2/28/03)
M136 Missing/incomplete/invalid indication that the service was supervised or evaluated by a
physician. Note: (Modified 2/28/03)
M137 Part B coinsurance under a demonstration project.
M138 Patient identified as a demonstration participant but the patient was not enrolled in the
demonstration at the time services were rendered. Coverage is limited to demonstration participants.
M139 Denied services exceed the coverage limit for the demonstration.
M140 Service not covered until after the patient’s 50th birthday, i.e., no coverage prior to the day after the 50th birthday Note: (Deactivated eff. 1/30/2004) Consider using M82
M141 Missing physician certified plan of care. Note: (Modified 2/28/03) Related to N238
M142 Missing American Diabetes Association Certificate of Recognition. Note: (Modified 2/28/03) Related to N226
M143 We have no record that you are licensed to dispensed drugs in the State where located.
M144 Pre-/post-operative care payment is included in the allowance for the surgery/procedure.

MA01 If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within 120 days of the date you received this notice, unless you have a good reason for being late.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)

MA02 If you do not agree with this determination, you have the right to appeal. You must file
a written request for an appeal within 120 days of the date you receive this notice. Decisions made by a Quality Improvement Organization (QIO) must be appealed to that QIO within 60 days.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)

MA03 If you do not agree with the approved amounts and $100 or more is in dispute (less deductible and coinsurance), you may ask for a hearing within six months of the date of this notice. To meet the $100, you may combine amounts on other claims that have been denied, including reopened appeals if you received a revised decision. You must appeal each claim on time. At the reconsideration, you must present any new evidence which could affect our decision.
Note: (Modified 10/31/02, 6/30/03, 8/1/05)

MA04 Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

MA05 Incorrect admission date patient status or type of bill entry on claim. Note: (Deactivated eff. 10/16/03) Consider using MA30, MA40 or MA43

MA06 Missing/incomplete/invalid beginning and/or ending date(s). Note: (Deactivated eff. 8/1/04) Consider using MA31

MA07 The claim information has also been forwarded to Medicaid for review.

MA08 You should also submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information as the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.

MA09 Claim submitted as unassigned but processed as assigned. You agreed to accept assignment for all claims.

MA10 The patient's payment was in excess of the amount owed. You must refund the overpayment to the patient.

MA11 Payment is being issued on a conditional basis. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources. Note: (Deactivated eff. 1/31/2004) Consider using M32

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