Revenue Cyle Management:

Patient

Reporting & Patient

Analytics Registration

Denial
Patient Visit
Management

Payment Medical
Posting Coding

Claims
Charge Entry
Adjudication

Clearing Claim
House Submission
CMS 1500 Questions:

1) 33 blocks
2) ROI is found in Block 12
3) AOB information is found on Block 13
4) Current date of injury is printed on Block 14
5) Tax Id is printed in Block 25
6) Patient Account number is printed on block 26
7) Patient’s name is printed in Block 2
8) Rendering provider name is printed on Block 32
9) PCP name is printed on block 17
10) The address where the treatment was given is printed in Block 32
11) The patient’s relationship to the insured is shown in Block 6
12) The diagnosis codes are printed on Block 21
13) Patient’s address is printed in Block 5
14) Dates of service are printed in Block 24a
15) The ‘Pay to address’ is printed in Block 33
16) UB-04 (or) CMS1450 has 81 Blocks
17) The block of CMS 1510 needs to be filled as per HIPAA is 12
18) If the patient is the policy holder’s daughter, block 6 of CMS 1510 has to be
checked as, Child
19) If the policy holder has a secondary insurance, block 11d of CMS 1510 would be
“YES”
20) The total amount billed by the provider on a claim is printed in block# 28
21) CMS 1510 has the policy id is printed in Block 1a
22) The rendering provider’s name is mentioned in block 31
23) Referral number is printed in block# 23
24) Group number is printed in block# 11
25) Plan name is printed in block # 11c
26) If block# 10a is checked as “Yes”, the claim is to be sent to Workers
Compensation
27) If block# 10b is checked as “Yes”, the claim is to be sent to Auto Liability
28) The subscriber’s gender is mentioned in block# 11a
29) The number denoting permission from the insurance is mentioned in block# 23
30) The provider will be paid directly if he selects “Yes” in this block# 27
31) The provider has to bill the patient for money if this block# 13 is left blank
32) This block# 14 must be filled in case of Worker’s compensation claims
33) The Place of Service is printed on block# 24b
34) The ICD codes are printed on block# 21
1. Diagnosis Code: (ICD Codes)

It is a combination of letters and/or numbers which is assigned to particular

illness/sickness, symptoms, or procedure

It is developed by WHO (World Health Organisation) as ICD (International

Classification of Disease) Code .

ICD code is redesigned by (CMS) Centers for Medicare & Medicaid Services

CMS revises this Codes as:

ICD-9-CM (9th Revision Clinical Modification)
ICD-10-CM (10th Revision Clinical Modification)

2. CPT:

CPT - Current Procedural Terminology which is designed by - American Medical

Association

It is 5 Digits Numeric - Alpha - Alpha Numeric

It is used to standardize the reporting of medical, surgical, and diagnostic services

and procedures performed in in-patient and out-patient settings.

3. Modifiers:

Modifiers are added to CPT or HCPCS codes inorder to give additional information to
the service without changing the service’s original meaning.

They are added to the end of a CPT/HCPCS codes with a hyphen (EX: 19302-LT)

Modifiers are numeric and alphanumeric

4. Two types of Claim Forms:

a. HCFA/CMS 1500 Claim Form

HCFA - Health Care Finance Administration

CMS - Center of Medicaid and Medicare Services

It consists of 33 blocks.

This claim form is used by individual doctors, nurses, and professionals, including
therapists, chiropractors, and out-patient clinics.

b. UB04/CMS145Uniform Billing0 Claim Form

UB - Uniform Billing
CMS - Center of Medicaid and Medicare Services

It consists of 81 blocks
This claim form is used by hospitals, nursing facilities, in-patient, and other facility
providers.

5. Place of Service:

POS - The Service/treatment where rendered by the provider to the patient.

It is Two-digit numeric

11 - Office Visit
21 - Inpatient Hospital
22 - On Campus-Outpatient Hospital
23 - Emergency Room – Hospital
24 - Ambulatory Surgical Center
31 - Skilled Nursing Facility
32 - Nursing Facility

6. In- Network Provider / Contracted Provider:

The provider who is contracted with the insurance company

Contractual adjustment is available

7. Out of Network Provider / Non-Contracted Provider:

The provider who is not contracted with the insurance company

Contractual adjustment is not available

8. Capitation:

It is like a montly salary / prepaid check given to the provider by the insurance
company

(or)

It is a method of payment only for Contracted/In -Network providers where a bulk

amount is paid in advance on every month like a salary

So, Insurance wont pay again and again for each visits.

9. Offset:

If the insurance company makes an excess payment or incorrect payment, then the
same amount will be adjusted in the next claim from the same provider and it need
not to be for the same patient.
10. Types of Authorization:

a. Referral Authorization:

RAN - Referral Authorization Number

PCP - Primary Care Physician

It is located in Block# 23 in CMS 1500 form

The PCP referring the patient to another provider/specialist is called Referral For
referring to another provider PCP will generate a number called Referral Number and
this has to be used by the Specialist while billing the claim to insurance.

If referral number missed to enter in the claim form by Specialist, then the claim will
be denied as missing “Referral number”

b. Prior Authorization:

Provider need to get approval/permission from the insurance to perform services (For
High Dollar Services).

If the insurance approves to perform the service, then they are wiling to pay for the
medical services .

c. Retro Authorization:

If the provider failed to get authorization, then he/she has a chance to get
authorization after the services rendered.

In other words, Getting authorization after the services is called retro authorization.

11. ABN - Advance Beneficiary Notice

Agreement between patient and provider

It is used for Medicare recipients

ABN form will be given to the patient by the provider before performing the services,
It is to inform the patient that if the insurance carrier denies the claim then the patient
is responsible to pay the provider.

If the provider missed getting a patient's sign in the ABN form then the provider
cannot bill the patient for non-covered services.

12. AOB - Assignment of Benefits

Patient and Insurance agreement

It is an agreement between the patient and insurance stating the patient agreeing to
send payment directly to the provider bank account or thru check

If AOB was not signed by the patient then payment will not be issued to the provider.
Then the Payment will be issued directly to patient.
13. ROI - Release of Information

Patient and provider agreement

It is an authorization given by the patient to the provider stating that the provider can
share the patient's personal health information with billing companies or to third
parties for billing purposes.

14. COB - Coordination of Benefits

To identify which insurance is primary, secondary and tertiary.

If the patient has more than one insurance plan, then the patient needs to update the
COB information to both insurances to update which insurance is primary and which
insurance is secondary.

15. Medicare:

Federal health insurance which is maintained by CMS(Centre for Medicaid and

Medicare services)

a. Eligibility:

American citizen or a permanent resident for at least five continuous years

A person should 65 years and above
Permanently/Temporarily disabled person.
ESRD – End Stage Renal Disease
A person who paid Medicare taxes while working for at least 10 years or 40 quarters.

b.Different Parts in Medicare:

Part A - Hospital ( Inpatient) - Covers Hopital Claims

Part B - Doctor (outpatient ) - Covers Physician CLaims
Part C - Medicare Advantage - Offered by private insurance companies which is
approved by Medicare
Part D - Prescription drugs - Covers Drug

16. Medicaid:

a. Federal health insurance which is maintained by states, according to federal

requirements.

b. Eligibility

People who are below the poverty line

If an annual income is less than the average income of an individual for a month
17. Managed Care Plan Types:

a. HMO: Health maintenance organization

It is an individual plan
PCP (Primary Care Physician) will be allocated.
Requires referral from PCP when patient referred to a Specialist
It covers only In-Network benefits
Out of network benefits not covered

b. POS: Point-of-Service

It is an individual plan
PCP (Primary Care Physician) will be allocated
Requires referral from PCP when patient referred to a Specialist
Both In-Network benefits and Out of network benefits covered

c. PPO: Preferred Provider Organization

It is a group plan
PCP (Primary Care Physician) and Referral not needed
A patient can directly meet Specialist
Both In-Network benefits and Out of network benefits available

d. EPO: Exclusive Provider Organization

It is a group plan
PCP (Primary Care Physician) and Referral not needed
A patient can directly meet Specialist
It covers only In-Network benefits
Out of network benefits not covered

18. Co-Pay:

It is the smallest fixed amount paid by a patient to the provider for each visit

19. Co-Insurance:

Coinsurance is a portion or percentage of the medical cost that patient pays after the
patient’s deductible has
been met.

In other words, Insurance pays 80 % and the remaining 20% patient will pay to the
provider

20. Deductible:

It is a fixed dollar amount that the patient has to pay to the insurance company before
it starts to cover the services
21. Out of pocket maximum:

(Deductibles + Co-payments + Co-insurances)

If the Out of pocket maximum is satisfied by patient then insurance pays 100% of
covered benefits.

22. Important Short Forms

EOB - Explanation of benefits

COB -Co-ordination of Benefits
ICD - International Classification of Diseases
CPT - Current procedural Terminology
HCPCS - Healthcare Common Procedure Coding System
HIPAA - Health Insurance Portability and Accountability Act
CHAMPUS - Civilian Health and Medical Program of the Uniformed Services
CHAMPVA - Civilian Health and Medical Program for the Veteran Administration
NCCI - National Correct Coding Initiative
ESRD - End-Stage Renal Disease
COBRA - Consolidated Omnibus Budget Reconciliation Act
PCP - Primary care physician
ABN: Advance Beneficiary Notice of Non-coverage
AMA: American Medical Association
CMS: The Centers for Medicare & Medicaid Services
EOB: Explanation of Benefits
ERA: Electronic Remittance Advice
SNF: Skilled Nursing Facility
SSN: Social Security Number
Non Denials:

1 - Claim in Process:

Steps to resolve :

1. Check previous notes for the earlier follow-ups

2. Get the claim received date
3. Get the normal processing time
4. If there is a delay, get the reason for the delay

Questions need to raise with rep:-

May I know the received date please?

Can I have the normal processing time?
(If FU days exceeds normal time)May I know the reason for the delay in processing?
Do you need any information to expedite processing?
When can I call back to check status of this claim?
May I have the claim number please?
Can I have the call reference number please?

2 - Claim Not on File:

Reasons:

1. The claims mailing address / electronic payor id was updated incorrectly in the
billing software. The Claim was filed to that incorrect address / payor id.
2. The claim has been rejected by the clearing house due to format errors
3. The claim has been filed to the insurance recently
4. The claim status has been checked with the incorrect insurance
5. The claim was never filed

Steps to resolve:

1. Check the claims filing history to check whether the claim was filed from our end
2. Get the correct claims mailing address/ electronic payor id from the previous notes
or previous paid claims or from insurance rep and file the claim to the updated claims
mailing address/ electronic payor id.
3. Look for errors in the submitted claim. Correct them and refile to the insurance.
4. If the claim has been filed recently, allow some more time. Set a follow-up date
based on the time it usually takes for a claim to reach the insurance.
5. Verify the insurance name, contact details before checking for claim status.

Questions need to raise with rep:

Can you confirm the payer ID?

Can you please check if the claim is rejected at the front end?
What is the claim’s mailing address?
Is the patient eligible for the Date of Service?
May I have the effective and termination dates of the patient's Plan?
What is the claim’s timely filing limit?
Does the patient have any other insurance active for the date of service?
Can I have the name of the other insurance name and their ID?
Do you accept electronic claims?
What is the payer ID to submit electronic claims?
May I have the reference number for this call please?

3 - Capitation:

It is like a montly salary / prepaid check given to the provider by the insurance
company
(or)
It is a method of payment only for Contracted/In -Network providers where a bulk
amount is paid in advance on every month like a salary
So, Insurance wont pay again and again for each visits.

Reason:
The treatment rendered is covered under the capitation contract executed by the
provider with the insurance.

Steps to resolve :

Check whether the provider is a contracted provider. If no, call insurance and request
the rep to reprocess the claim.
If yes, Check whether the procedure code is covered under the capitation contract.
If No, request the rep to reprocess the claim.
If Yes, check whether the DOS falls within the contract period.
If No, check whether there are any claims paid recently for the provider for the same
procedure within the contract period.
If Yes, request the rep to reprocess the claim.
If No, suggest provider to write-off balance.

Questions need to raise with rep:

May i know the received date?

May i know the Claim processed date?
May I know the Capitation period? - (Get the start and end date of Capitationperiod)
If the DOS is lies between the capitation period then this claim should be write-off
If the DOS is not lies between the capitation period then ask the rep to reprocess
If the insurance is Medicare/Medicaid the get the managed care plan details like
payer name and member id (claim need to resubmit to managed care plan)
May i know the Claim#
May i know the Call reference#
Thank you.

4 - Deductible

It is a fixed dollar amount that the patient has to pay to the insurance company before
it starts to cover the services

Reason:
The patient has not met the annual deductible.

Steps to resolve :

Get the allowed amount, patient responsibilities, paid amount

Get the amount applied to patient’s deductible
Check whether the allowed amount = deductible applied.
If there is a balance in the allowed amount after applying the deductible, get the
break-up of the balance.
Need to get the details about the deductible like,
If it is applied In-network or Out-of-network
Whether it is an individual deductible or a family deductible
The periodicity of applying the deductible – Annual or Lifetime
How much has the patient met on the deductible amount?
If the deductible amount has been met, when did the patient meet the deductible
amount?

Questions need to raise with rep:

When was the claim processed?

What is the allowed amount?
What amount was applied to the patient's deductible?
Was this claim processed as in network or out of network?
Was the claim applied to the in network or out of network deductible?
What is the patient's calendar year deductible?
How much of the deductible has the patient met?
(If partial allowed amount is applied to deductible)Was there any payment made
towards the provider?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?

5 - Offset

If the insurance company makes an excess payment or incorrect payment, then the
same amount will be adjusted in the next claim from the same provider and it need
not to be for the same patient.

Questions need to raise with rep:

May i know the Claim received date?
May i know the Claim processed date?
May I know the allowed amount for this claim?
May i know patient responsibilities on this claim? (Get the pt resp to bill patient)
May i knmow the Offset amount?
May i know whether the offset made on same patient account or different patient
account?
Could you please provide me over-paid patient account#, check#, DOS & CPT code?
Could you please fax the EOB?
if rep refused, ask to send the EOB to the provider mailing address.
May i know the Claim#
May i know the Call reference#
Thank you.

Once the EOB received then send it for posting.

6 - Paid

Reasons:

The check would have been issued recently.

The check would have been received at the provider’s office but not posted
The check would have been received at the provider’s office but not encashed
The check would have been delivered to an incorrect address

Steps to resolve:

Check whether the payment has been processed correctly by getting the allowed
amount, patient responsibility, paid amount from the EOB (if available) or with the
rep on call
Check the mode of payment – Check or EFT from the EOB or with the rep on call
If EFT – verify whether the payment was linked to the correct TIN of the provider with
the rep
If Check – Get to know when the check was issued , the check number and the
check amount
Verify whether the check has been sent to the correct ‘Pay To address’ either from
the EOB or with the rep on call
If Yes, then verify whether the check has been issued within 30 business days from
the current date. If so, wait for the check to arrive.
If the check has been issued more than 30 business days from current date, ask the
rep regarding the encashment status.
If the check has been encashed, ask the rep for a copy of the cancelled check
If the check has not been encashed, ask the rep to cancel the check and issue a
fresh check.
If the check has been sent to an incorrect address, enquire the rep whether the
check has been encashed.
If encashed, ask the rep for a copy of the cancelled check.
If not encashed, fax a copy of W9 form to the insurance to update the correct
address
Request the rep to cancel the check issued to the incorrect address and issue a fresh
check to the correct address.

Questions need to raise with rep: – PAID VIA CHECK

When did the claim get processed and paid?

What was the allowed amount?
What was the paid amount?
Is there any patient responsibility?
What is the provider contractual amount?
Were all the procedures on the claim paid?
Can I have the breakdown of the payment please?
Was it paid through a check or EFT?
What is the check number?
What is the check date?
What is the check amount?
Was it a single or bulk check?
What address was the check sent to?
Was the check cashed?
Can you fax me a copy of the cashed check along with the EOB?
May I have the claim number please?
May I have the call reference number please?

Questions need to raise with rep: – PAID VIA EFT

What is the status of the claim?

When did the claim get processed and paid?
What was the allowed amount?
What was the paid amount?
Is there any patient responsibility?
What is the provider contractual amount?
Were all the procedures on the claim paid?
Can I have the breakdown of the payment please?
Was it paid through a check or EFT?
What is the EFT number?
What is the EFT date?
What is the EFT amount?
Was it a single or bulk EFT?
Do you have an EFT transaction number?
Can you fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
Denials:

1 - Primary Paid maximum

Reasons:

This denial would be received only from a secondary payer for the following reasons:
The allowed amount of the secondary insurance would be very less for a specified
procedure.
The primary insurance would have a higher % paid amount. It is calculated as
(Primary Paid/Primary Allowed)

Steps to resolve :

Check if the insurance is Primary or Secondary, if it’s from Primary payer then patient
need to update COB information to the Payor.
Compare the secondary allowed amount from Secondary EOB with the primary paid
amount from the primary EOB.

Questions need to raise with rep:

Claim received date?

Claim denied date?
secondary allowed amount?
Check the primary paid amount in primary EOB, if primary paid more than secondary
allowed then adjust the claim
If primary paid is less than secondary allowed then ask the rep to reprocess.
Claim#
Call reference#
2 - Denied for Primary EOB:

Reasons:
The patient has changed the COB information but has not updated the provider .
The secondary insurance has been incorrectly updated as primary in the billing
software.
The patient has updated the COB form with the incorrect primary and secondary
details.

Steps to resolve :
Check whether the COB information has been updated in the billing software as per
the COB form
If the COB information has been updated incorrectly in the billing software, update
the information as per COB form. Verify the eligibility on DOS with the updated
primary insurance carrier and if eligible, file the claim to them.
If the patient was not eligible on DOS, need to call the secondary insurance and
verify if they can act as a primary for the DOS.
If the secondary insurance cannot act as primary, check with them for any other
active coverages.
If found, verify eligibility on DOS. If eligible, file the claim to them. If not, suggest to
bill patient.
If Yes, need to call the insurance and verify what is the primary insurance as per their
records.
If there is no change in primary insurance details for the DOS, request the rep to
reprocess the claim.
If there is a different primary insurance, need to get the Secondary Effective Date for
the current insurance.
Need to check for any recent claims paid by the current carrier as primary after the
Secondary Effective Date.
If Yes, request the rep to reprocess the claim.
If No, Verify the eligibility on DOS with the updated primary insurance carrier and if
eligible, file the claim to them.
If the patient was not eligible on DOS, suggest to bill the patient for getting the
correct COB information

Questions need to raise with rep:

Claim received date?
Claim denied date?
Check system for primary eob, if we have primary eob then ask the mailing address
and TFL to resubmit the claim with primary eob
If we are not having primary eob also we don't know who is primary, then ask rep
about primary payer details like primary payer name, primary payer member id#, and
primary payer phone number#
Claim#
Call reference#
3 - Denied as Duplicate:

Reasons:
The procedures on the claim could have been done more than once on the same
DOS due to medical necessity either by the same physician or two different
physicians.
The claim could have been refiled as the original claim never reached the insurance
and the original claim has been received eventually.
The service was performed by another provider, outside of your practice or group, on
the same day as your service, and payment has already been made to that provider.
The same claim was generated twice as the same charge sheet was processed by
two different Charge Entry operators.
A corrected claim was sent.

Steps to resolve :
Check whether the billing software shows more than one claim for the same DOS.
If there is only one claim, check the claim filing history to know how many times the
same claim was refiled.
If there was a refiling made need to get the status of the original submission.
If there were two claims, need to check if there are appropriate modifiers to
differentiate the claims. If yes, need to call the insurance and request them to
reprocess the claim.
If there were no proper modifiers, then we need to move the claim for coding review
to check whether there was a medical necessity and get relevant modifiers coded.
If the denial was a corrected claim, need to call the insurance and mention the
differences, request them to reprocess.
If the claim was generated due to charge entry errors, suggest to write-off the denied
claim.
The service was performed by another provider, outside of your practice or group-
This can only be resolved by contacting the insurance company. Ask the insurance
company for their policy on appealing such a denial, each insurance has their own
process for doing this.

Questions need to raise with rep:

When did the claim get denied?
May I know to which claim it is being denied as duplicate?
What is the status of the original claim?
What are the rendering provider names on the initial claim and the denied claim?
What are the procedure codes and Diagnostic codes on the initial claim and the
denied claim?
Do you show or have a modifier on the claim to indicate same service provided on
the same day by the physician?
What is the appeals' address?
What is the appeals' filing limit?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?

4 - Patient not Eligible or Not active:

Reasons:
The patient's insurance coverage having been terminated prior to receiving the
services.
The patient’s insurance policy included on the claim was not eligible for the date of
service billed.
The patient’s eligibility on DOS was not verified before providing the treatment.

Steps to resolve :
Ensure you have a copy of the patient’s most recently issued insurance card copy.
Verify that the member ID# on the patient’s insurance card is the same member ID#
that was entered on the patient insurance setup screen.
Verify eligibility with the payer by Call or via online, if the patient is an eligible
member, by collecting policy start and end dates.
If patient’s benefits were not active for the date of service on the claim, suggest to bill
patient or check for other insurance. We need to act based on the client specification.

Questions need to raise with rep:

Can I have the denial date please?
May I have the effective and termination dates of the patient's Plan?
(If active) Can you reprocess this claim as I see that the patient was eligible for the
date of service?
How long would this claim take to reprocess?
(If not active) Does the patient have any other insurance active for the date of service?
May I have the claim number please?
May I have the call reference number please?

5 - Denied for Authorization missing / Invalid

Reasons:

The provider has given the treatment without obtaining the authorization from the
insurance
The treatment is an emergency treatment
The hospital has already obtained an authorization for the same treatment.

Steps to resolve :

Check whether the POS code is ‘23’. If yes, need to call the insurance and request
the claim to be reprocessed.
Check whether the POS code is ’21’. If yes, need to call the insurance and verify
whether the hospital claim has a pre-certification number.
If the POS code is anything apart from ‘23’ or ’21’, need to check whether the billing
software has a prior authorization number updated. If yes, need to call insurance and
validate the prior authorization number.
If the prior authorization number is not valid or it is not updated in the billing software,
need to enquire the insurance if they can accept a retro-authorization.
If there is no prior authorization number and a retro authorization is not accepted,
need to check with client for further action.

Questions need to raise with rep:

May I know when the claim was denied?

(If Auth available in system)Can you please verify the authorization that I have on file?
Is that valid for this date of service?
(If POS is 23) Can you please reprocess the claim as the service is related to
emergency and it does not require authorization?
(If POS is 21)Do you have a hospital claim on file for this patient and date of service?
Can you please use the hospital authorization to process this claim?
(POS other than 21 & 23) Can we get a retro Authorization for this claim?
(If yes)Can I have the address and the telephone number of the Utilization Review
department?
(If no retro possible)May I have the appeals address?
What is the appeals filing limit?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
6 - Denied for Referral missing / Invalid

Reasons:

The patient has met the specialist without the permission of the PCP
The PCP has treated the patient
The plan does not need a PCP and a referral
The service is an Emergency service
The referral number mentioned on the documents is not updated in the software

Steps to resolve :

Check whether the PCP has given the treatment as a rendering physician. If yes,
need to call insurance and request for reprocessing.
Check whether the service is an emergency service [POS Code = 23]. If yes, need to
call insurance and request for reprocessing.
Check whether the plan is a HMO or POS [In-network provider]. If No, need to call
insurance and request for reprocessing.
Check whether the referral number has been updated in the billing software. If Yes,
need to call insurance and request for reprocessing.
Check whether the referral number is available in any of the documents, previous
notes. If Yes, need to update the same in the billing software and send in a corrected
claim.
If still there is no referral number, need to call the insurance and enquire whether
they accept a back-dated referral. If Yes, need to get the PCP name, PCP telephone
number.
If a back-dated referral is not accepted, suggest to bill patient.

Questions need to raise with rep:

May I know when the claim was denied?

What type of plan does the patient have?
(If PPO) Can you please send the claim back for reprocess as the PPO plan does not
require referral?
(If POS & Provider In-network) Can you please send the claim back for reprocess as
the POS plan does not require referral if the provider an In-network provider?
(If POS & Provider In-network)
(IF HMO)Do you have a referral on file?
(If referral number in system) - Can you please validate the referral that I have on file?
(If paper referral) Can I fax you the referral that I have on file?
What address can I send this referral to?
Who is the patient's PCP?
What is the PCP's telephone number?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
7 - Denied as Inclusive:

Reasons:
The procedure code denied is included in the other procedure code.
The procedure code denied cannot be done alone. It has to be done in combination
with the other code
The denied procedure code which is a part of some other code is the ‘Component’
procedure code. The other procedure code is the ‘Comprehensive Code’, as it
includes another procedure code.

Steps to resolve :
Need to identify the ‘Component procedure code’ [denied procedure code] from the
EOB. The ‘Comprehensive procedure code’ [the procedure code which includes the
denied code] shall be identified from the billing software or from the insurance rep on
call.
Check the NCCI edits either through any of the coder tools or through the CCI Edit
spread-sheets from CMS website. This is done to identify if the denied procedure
code has any coding conflict with the Comprehensive procedure code.
If there is no coding conflict, call the insurance and request to reprocess the claim.
If there is a coding conflict, need to check whether a modifier can be used. If yes,
need to raise a Coding review for getting appropriate modifiers.
If a modifier cannot be used, then need to raise client review for further action.

Questions need to raise with rep:

When did the claim get denied?
Can I have the denied procedure code?
What is the primary procedure to which the denied service is included?
What is the status of the primary procedures?
Can you please reprocess the claim as the denied service is billed with the
appropriate modifier to indicate that the service require separate payment?
Can I send in a corrected claim with the modifier?
What is the address to submit the corrected claim?
What is the Corrected claim’s filling limit?
What is the appeals address?
What is the appeals filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?

8 - Denied as Non Covered Service:

Reasons:
The service is not payable as per the patient’s plan.
The service is not payable as per the provider’s contract.

Steps to resolve :
Check whether the service is not payable under the patient’s plan or the provider’s
contract.
Check for any previous paid claims for the same patient, same procedure, same
provider by the same insurance.
If Yes, need to call the insurance and request to reprocess the claim.
If No:
For Non-covered charges as per patient’s plan – suggest to bill patient
For Non-covered charges as per provider’s contract – raise client review.

Questions need to raise with rep:

May I know when the claim was denied?
Was that denied based on the patient plan or provider’s contract?
(Provider’s contract) May I know when did you stop paying for the service?
Can you please fax the documentation which explains the same?
(Patient’s Plan) Can you please double check if the service is not covered under the
patient’s plan?
Does the patient have any other insurance active for the date of service?
(If Yes) Can I have the name of the other insurance name and their ID?
Can you fax me a copy of the EOB please?
Can this claim be appealed?
What is the appeals’ address?
What is the appeals’ filing limit?
May I have the claim number please?
May I have the call reference number please?

9 - Denied as Not Medically necessary:

Meaning:
Medical necessity is defined as accepted health care services and supplies provided
by health care entities appropriate to the evaluation and treatment of a disease,
condition, illness or injury and consistent with the applicable standard of care.

Reasons:
The treatment does not appear to meet medical necessity criteria
The treatment cannot be medically certified based on the information provided by the
treating clinician, or the treating clinician’s designated representative.
The procedure code is billed with an incompatible diagnosis
Payment purposes and the ICD-10 code(s) submitted is not covered under a Local or
National Coverage determination (LCD/NCD)

Steps to resolve :
LCDs specify under what clinical circumstances a service is considered to be
reasonable and necessary for the diagnosis or treatment of illness or injury, or to
improve the functioning of a malformed body part.
Refer to LCD and procedure to diagnosis lookup tool, to determine if a current and
draft LCD exists for the denied procedure code.
If the LCD exists for the procedure code, need to call the insurance and request to
reprocess.
If the LCD does not exist, need to check if there are any previous paid claims with the
same set of codes for the same patient. If yes, need to call insurance and request to
reprocess the claim.
If not, need to check with the insurance what are the documents acceptable as proof
of Medical Necessity and send out an appeal with the relevant documents.

Questions need to raise with rep:

What is the status of the claim?
When did the claim get denied?
Do you need the medical necessity letter or the medical records to process the claim?
What is the address to submit the medical necessity letter /medical records?
What is the appeals’ address?
What is the appeals’ filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?
10 - Denied for Maximum Benefits Exhausted

Meaning:
A benefit maximum is a limit on a covered service or supply. A service or supply may
be limited by dollar amount, duration, or number of visits.
The current insurance has already enough paid for this patient hence this insurance
can’t pay more.
Patient coverage is active but insurance will not pay since the amount of maximum
payable has been reached.
Some insurance companies limit the dollar amount they will pay per year for certain
services, or they limit the quantity of services eligible for coverage per year.

Reasons:
This denial can be for many reasons such as:
Annual Benefit Amount
Individual Lifetime Visits
Visit Limit
Dollar Limit
Maximum units exceeded for Medical Policy

Steps to resolve :

Check the benefit details online or on call – whether the benefit limit is visit based or
amount based, the number of visits or the maximum amount allowed.
Check if there is a balance in the benefit limit. If found request to reprocess the claim.
If not, check the system to see if the patient has any secondary insurance.
If there is no sufficient information provided in the system then go back to the original
file in which the patient’s insurance information was received and if there is a
secondary insurance, the claim can be submitted to the secondary insurance
If it does then re-file claims to that insurance.
If patient does not have any other insurance, bill the patient for allowed amount.

Questions need to raise with rep:

Can I have the denial date please?

May I know if the claim was denied based on the no of visits or dollar value?
(If no of visits) May I know the total no of visits for the calendar year please?
(If by dollar value) May I know the total dollar value for the calendar year please?
Was the claim processed in or out of network?
When the patient has exhausted these benefits?
Does the patient have any other insurance active for the date of service?
Can I have the name of the other insurance name and their ID?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
11 - Denied as Global Procedure:

Meaning: A global period is a period of time starting with a surgical procedure and
ending some period of time after the procedure. Many surgeries have a follow-up
period during which charges for normal post-operative care are bundled into the
global surgery fee. The global surgical package is a single payment for all care
associated with a surgical procedure. The payment is based on three phases of a
surgical procedure.
Pre-operative evaluation.
Intra-operative procedure.
Postoperative care for either zero (0), ten (10), or ninety (90) days.

The follow-up procedure done during the global period is called a global procedure.

Reasons:
The follow-up procedure was performed related to the surgery procedure
The follow-up procedure was performed during the global period

Steps to resolve :

Check whether there was any surgical procedure performed up to 90 calendar days
prior to the follow-up procedure DOS.
If No, need to call insurance and request to reprocess.
If Yes, need to get the global period for the surgery code.
Check whether the follow-up procedure code was performed within the global period.
If No, need to call insurance and request to reprocess.
If Yes, check whether the diagnosis codes billed with the surgery procedure and the
follow-up procedure code are matching.
 If No, need to call insurance and request to reprocess.
If Yes, need to raise client review for further action.

Questions need to raise with rep:

When did the claim get denied?

What CPT was the claim denied global to?
What is the date of service of the CPT that was global?
What is the global period for the surgery procedure?
Does the original claim have a 24 modifier to indicate that it's not a global procedure?
Can you have this claim reprocessed as this CPT is not considered global?
Can this claim be appealed?
What is the appeals’ address?
What is the appeals’ filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?

Get the denied date, denied procedure code,. Get

diagnosis code

Any surgical
No
procedure performed 90 days
before DOS?

Yes

Get the surgery procedure code, surgery diagnosis code, global period Request the rep to
of surgery procedure code. reprocess the claim.

Get the claim # Call

ref#
DOS falls No
within global period?

Yes

Surgery No
diagnosis Code = Follow-up
diagnosis code ?

Yes

Raise client review.

Get claim#, call ref#
12 - Denied For TFL:

Meaning: The claim has been received at the insurance after the filing limit.

Reasons:
The claim has been submitted originally after the filing limit
The claim has been submitted originally within the filing limit, but was received by the
insurance after the filing limit.

Steps to resolve :
Check whether the claim received date was within the filing limit
If it was within the filing limit , need to call the insurance and ask to reprocess the
claim
If it was received out of the filing limit, need to check the original submission date.
If the claim was submitted within the filing limit, need to call the insurance and ask for
the documents accepted as Proof of Timely Filing [POTF]
If the claim was submitted after the filing limit , need to raise a client review.

Questions need to raise with rep:

When did this Claim get denied?

When did you receive the claim?
What is the claim's filing limit?
Please reprocess this claim as it was received within the filing limit.
(If claim filled after the filling limit)What is the appeals' address?
What is the appeals' filing limit?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
13 - Denied for COB information:

Meaning: The insurance billed is the secondary insurance. Some other insurance is
primary.

Reasons:
The patient has changed the COB information but has not updated the provider .
The secondary insurance has been incorrectly updated as primary in the billing
software.
The patient has updated the COB form with the incorrect primary and secondary
details.

Steps to resolve :
Check whether the COB information has been updated in the billing software as per
the COB form
If the COB information has been updated incorrectly in the billing software, update
the information as per COB form. Verify the eligibility on DOS with the updated
primary insurance carrier and if eligible, file the claim to them.
If the patient was not eligible on DOS, need to call the secondary insurance and
verify if they can act as a primary for the DOS.
If the secondary insurance cannot act as primary, check with them for any other
active coverages.
If found, verify eligibility on DOS. If eligible, file the claim to them. If not, suggest to
bill patient.
If Yes, need to call the insurance and verify what is the primary insurance as per their
records.
If there is no change in primary insurance details for the DOS, request the rep to
reprocess the claim.
If there is a different primary insurance, need to get the Secondary Effective Date for
the current insurance.
Need to check for any recent claims paid by the current carrier as primary after the
Secondary Effective Date.
If Yes, request the rep to reprocess the claim.
If No, Verify the eligibility on DOS with the updated primary insurance carrier and if
eligible, file the claim to them.
If the patient was not eligible on DOS, suggest to bill the patient for getting the
correct COB information.

Questions need to raise with rep:

May I know when the claim was denied?

When the Coordination of Benefits was last updated?
Was a questioner sent to the patient to update the Coordination of Benefits?
When was the last questioner sent to the patient?
Did the patient respond to your last letter?
Can you send another questioner to the patient to update the Coordination of
Benefits?
Can you please fax me a copy of the EOB?
May I have the claim number please?
May I have the call reference number please?
14 - Denied for missing / invalid Modifier:

Meaning: Submitted information on claim form such as Provider, patient and

insurance along with charges were incomplete

Reasons:
Multiple reasons to deny claim as information submitted is incorrect / invalid.
Any information which is related to Provider, patient, insurance and charges billed on
claim form should be accurate with insurance data base.
Any of the information incomplete will lead to this denial and correspondence will
help us to identify the same.

Steps to resolve :
These claims will be returned as unprocessed claims as rejections and corrections
would be required. The below cases are related to coding and need to be referred to
the Coding team for a review. Alternative codes shall be assigned , if needed.
Diagnosis code is missing, or are invalid: Billed diagnosis code is incorrect - Claim
must have been filed with old diagnosis code version. Claim must have filed without
diagnosis codes. The current version of diagnosis codes is to be used.
Procedure modifier was invalid on the date of service : This can mean the procedure
code/modifier combination is invalid or the procedure code or modifier is invalid.
Check current CPT guidelines to verify the procedure, modifier and/or the
combination are valid for the date of service.
Invalid place of service - Treatment was deemed by the payer to have been rendered
in an Example: A code described as an outpatient service would not be valid if billed
with an inpatient POS.
Procedure code was invalid on the date of service: Billed procedure code is incorrect
/ invalid for billed date of service - Claim must have been filed with old procedure
code which is invalid for date of service. The active procedure codes are to be used
as per current CPT guidelines.

Questions need to raise with rep:

When did the claim get denied?

What is the modifier that you see on the claim?
Can you please reprocess the claim with the correct information that is available?
Can I send in a corrected claim with the modifier?
What is the address to submit the corrected claim?
What is the Corrected claim’s filling limit?
What is the appeals address?
What is the appeals filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?
15 - Denied for invalid Place of service:

Meaning: Submitted information on claim form such as Provider, patient and

insurance along with charges were incomplete
/invalid.

Reasons:
Multiple reasons to deny claim as information submitted is incorrect / invalid.
Any information which is related to Provider, patient, insurance and charges billed on
claim form should be accurate with insurance data base.
Any of the information incomplete will lead to this denial and correspondence will
help us to identify the same.

Steps to resolve :
These claims will be returned as unprocessed claims as rejections and corrections
would be required. The below cases are related to coding and need to be referred to
the Coding team for a review. Alternative codes shall be assigned , if needed.
Diagnosis code is missing, or are invalid: Billed diagnosis code is incorrect - Claim
must have been filed with old diagnosis code version. Claim must have filed without
diagnosis codes. The current version of diagnosis codes is to be used.
Procedure modifier was invalid on the date of service : This can mean the procedure
code/modifier combination is invalid or the procedure code or modifier is invalid.
Check current CPT guidelines to verify the procedure, modifier and/or the
combination are valid for the date of service.
Invalid place of service - Treatment was deemed by the payer to have been rendered
in an Example: A code described as an outpatient service would not be valid if billed
with an inpatient POS.
Procedure code was invalid on the date of service: Billed procedure code is incorrect
/ invalid for billed date of service - Claim must have been filed with old procedure
code which is invalid for date of service. The active procedure codes are to be used
as per current CPT guidelines.

Questions need to raise with rep:

When did the claim get denied?

Why was it denied as invalid or incorrect POS?
What POS do you see on the original claim?
Can you have the original claim reprocessed as the POS is correct?
What is the claims' reprocessing time?
Can I send in a corrected claim with the correct POS?
What is the address to submit the corrected claim?
What is the Corrected claim’s filling limit?
Can this claim be appealed?
What is the appeals address?
What is the appeals filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?
May I have the call reference number please?
16- Denied for Invalid DX or CPT code:
Meaning: Submitted information on claim form such as Provider, patient and
insurance along with charges were incomplete

Reasons:
Multiple reasons to deny claim as information submitted is incorrect / invalid.
Any information which is related to Provider, patient, insurance and charges billed on
claim form should be accurate with insurance data base.
Any of the information incomplete will lead to this denial and correspondence will
help us to identify the same.

Steps to resolve :
These claims will be returned as unprocessed claims as rejections and corrections
would be required. The below cases are related to coding and need to be referred to
the Coding team for a review. Alternative codes shall be assigned , if needed.
Diagnosis code is missing, or are invalid: Billed diagnosis code is incorrect - Claim
must have been filed with old diagnosis code version. Claim must have filed without
diagnosis codes. The current version of diagnosis codes is to be used.
Procedure modifier was invalid on the date of service : This can mean the procedure
code/modifier combination is invalid or the procedure code or modifier is invalid.
Check current CPT guidelines to verify the procedure, modifier and/or the
combination are valid for the date of service.
Invalid place of service - Treatment was deemed by the payer to have been rendered
in an Example: A code described as an outpatient service would not be valid if billed
with an inpatient POS.
Procedure code was invalid on the date of service: Billed procedure code is incorrect
/ invalid for billed date of service - Claim must have been filed with old procedure
code which is invalid for date of service. The active procedure codes are to be used
as per current CPT guidelines.

Questions need to raise with rep:

When did the claim get denied?

Why has it been denied as invalid or incorrect CPT?
Which CPT is invalid or incorrect?
Can I send in a corrected claim with the correct procedure?
What is the address to submit the corrected claim?
What is the Corrected claim’s filling limit?
Can this claim be appealed?
What is the appeals address?
What is the appeals filing limit?
Can you fax me a copy of the EOB please?
May I have the claim number please?