Deductible Amount:

Events in the Scenario:

Deductible: The policyholder must pay a predetermined sum before the insurance company begins to
reimburse the treatment.

For instance, let's say a policyholder has a $2,000.00 deductible and needs to pay $1,500.00 for
treatment. Therefore, the policyholder will be responsible for paying the deductible amount when this
claim is billed to insurance.

In the event that the policyholder needs a second, $1,200.00 treatment, the insurance will pay the
remaining $700 after deducting $500.00 from the patient's deductible. Depending on the terms of the
policy contract, patient responsibility may also be included when processing $700.00 as coinsurance or
copayment. $500.00 will be the deductible amount that the policyholder must pay.

The deductible clause may specify a visitation limit or a monetary amount.

In the event that it is visit-based, the policyholder will be in charge of covering the whole cost of
treatment up until the permitted visit.

Situation of On Call:

Application for Deductible Claims

Could you tell me when it was processed?

What is the Allowed Amount(AA)?

What is the policy's total deductible limit?

How much of the patient's claim has been fulfilled?

↙ ↘

If the patient has met the deductible, including this claim; if the patient has already met the
deductible; if the patient has not met the deductible, including this claim; if the patient has not met the
deductible, excluding this claim
 Would you kindly fax the EOB to me? Should that be the case, kindly mail it. Could you also
forward the claim or the link to the appropriate EOB source? returned for
reprocessing because the patient has already met his

Could you please provide the claim number and call reference number?
Deductible not applying to this claim?

What is the Turn around

time(TAT) for reprocessing?

Would you please provide the claim#

and call reference number?

Important Notes:
 Kindly follow your process update by taking appropriate action. The actions listed below might
differ from your process update.
 When the EOB arrives by fax, make a note of the account and forward it for posting. If the EOB is
delivered by mail, make a note of the account as well.
 You can schedule the follow-up for the representative's specified TAT if the claim is returned for
additional processing.
 A secondary or subsequent payer may be billed for the claim after the deductible has been
posted. It is necessary to confirm the patient's eligibility for a secondary or consecutive payer
before billing the claim to one of these payers.
 Check the payer website if you want to confirm a secondary or consecutive payer's eligibility.
 Rebill the claim if the patient policy is active for subsequent or secondary payers on DOS.
 Once the deductible is posted, release the claim to the patient if there isn't another payer
available or active on DOS.
 Medicare always forwards claims to the subsequent payer when they are used by the Medicare
payer toward their deductible. In this instance, call the insurance company to find out the status
if the processed date has passed and we have not heard back from any successive payers after
30 days.
 In certain cases, the claim may be handled as out-of-network, in which case the full amount may
be billed to the secondary or subsequent payer without the need for an adjustment. In the
event that no other payer

4: The procedure code inconsistent with the

modifier used or a required modifier is
missing
Situation of On Call:

The claim was rejected due to the procedure code being inconsistent with
the modifier used.

May I get the denial date?

Check patient payment history if the same

CPT code paid with the same modifier

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What is the deadline for receiving
payment for the same CPT and modifier? send corrected claim?

↓ ↓

How long does it take to reprocess? What is the mailing or fax number for an
appeal?

Could you please provide the claim number and call reference number?
↓

How much is the time limit

to send an appeal?

May I have the claim# & call ref#?

Important Note:
 If the deadline for submitting the corrected claim is not missed, the coding team should be
tasked with reviewing this denial and providing the appropriate modifier. After receiving a
response with the correct modifier details, the corrected claim should be submitted to the
insurance.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team determines that the modifier is accurate.
  Calculate the time limit from the denial date before filing an appeal. If the time limit is not
exceeded, file the appeal; if it is, write off the claim.
 Work in accordance with the client's request, which occasionally requires us to send the appeal
after the deadline has passed.
 Insurance will need to send the CPT in a single line using a bilateral modifier (50) in the event
that the same CPT is billed with both the LT and RT modifiers, one of which is already paid and
the other is rejected as an invalid modifier. In order to double the charge amount, voide both
CPTs, make a new line with a 50 modifier, and submit the updated claim to insurance.
 Send the void claim for paid CPT to insurance first, then send a new claim with a 50 modifier
since Medicare will not accept the amended claim.

5: The procedure code/type of bill is

inconsistent with the place of service

Situation of On Call:

The procedure code or type of bill is inconsistent with the place of service,
hence the claim is denied.

MayI have the date of denial please?

Would you kindly let me know the proper location for the service?

↙ ↘

In the event that the representative offers

What is the deadline for Would you kindly verify and submit the
updated claim? Is there a paid hospital claim associated with the same DOS?

Could I please have the claim# and call reference number? No

Yes

↓ ↓

What is the deadline? ← What is the point of sale (POS) in

order to submit a corrected claim? the hospital's assertion?
 Could you please give me the call reference number and claim
number?

Important Note:
 Update the POS and send the corrected version to insurance if the representative provides the
accurate version. Always submit new claims to Medicare as they will be accepted, even if the
claim has been corrected.
 Assign the claim to the coding team so they can examine it and supply the correct POS if the
representative fails to supply the correct one.
 Work accordingly after you hear back from the coding team. If the representative disagrees, get
the details for the appeal and submit an appeal to the insurance company. If the response
regarding the coding is accurate, call the insurance company and attempt to reprocess the claim.

6: The procedure/revenue code is

inconsistent with the patient's age

Situation of On Call:

Claim rejected because procedure code is not in line with patient's age

MayI have the date of denial?

Examine the patient's payment history if the same CPT was paid for by the
same insurance.

Yes No

↓ ↓

Would you kindly process the claim again as What's the cutoff date for receiving
payment for the same CPT? Please submit the updated claim.

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

What is the duration within which an appeal can be

sent?
 Could you please provide the claim number and call
reference number?

Important Note:
 Not many CPTs are defined according to the patient's age. This denial happens when it is billed
incorrectly.
 The coding team should be tasked with reviewing this denial and providing the appropriate
procedure code.
 At times, the insurance representative offers further details regarding the maximum age at which
the billed CPT can be utilized. When giving it to the coding team, you can make note of that
information in the notes.
 If the deadline for submitting the amended claim is not missed, submit the corrected claim to
insurance by updating the CPT code as soon as you receive a response with the correct CPT
details.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team certifies that the procedure code is coded
accurately.
 Calculate the time limit from the denial date before filing an appeal. If the time limit is not
exceeded, file the appeal; if it is, write off the claim.
 Work accordingly because there are situations when the client requests that we send the appeal
even after the deadline has passed.

7: The procedure/revenue code is

inconsistent with the patient's gender

Situation of On Call:

Claim rejected because the procedure code does not match the patient's
gender

MayI have the date of denial?

Examine the patient's payment history if the same CPT was paid for by the
same insurance.
 Yes No

↓ ↓

Would you kindly process the claim again as How much time does it take to receive
payment for the same CPT? Please submit the updated claim.

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

What is the duration within which an appeal can be

sent?

Could you please provide the claim number and call

reference number?

Important Note:
 The CPT is not very gender-specific. For instance, only females are eligible to have CPT 77067
(Breast Mammography) billed. This denial will occur if the male billing is incorrect.
 Always confirm the patient's eligibility before submitting a claim after receiving a denial, as
patient information may have been updated incorrectly regarding gender.
 The coding team should be tasked with reviewing this denial and providing the correct procedure
code if the patient's gender is accurate on the website as well. If the deadline for submitting the
amended claim is not missed, submit the corrected claim to insurance by updating the CPT code
as soon as you receive a response with the correct CPT details.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team certifies that the procedure code is coded
accurately.
 Calculate the time limit from the denial date before filing an appeal. If the time limit is not
exceeded, file the appeal; if it is, write off the claim.
 Work in accordance with the client's request, which occasionally requires us to send the appeal
after the deadline has passed.

8: The procedure code is inconsistent with

the provider type/specialty (taxonomy)

Situation of On Call:
 The claim has been rejected due to the procedure code not matching the
provider type or specialty.

Canyou please let me know when the application was denied?

What is the precise cause of the denial?

Specialization of the provider is not The taxonomy code is missing. You are
authorized to perform this service. It is not included in the claim form.

Verify the specialty of the provider. Which taxonomy code is missing from the
claim form on the NPPES website, at which box number?

The NPPES website can be accessed by clicking this link. ↑

Simply enter NPI of rendering provider. Verify the claim form's NPI Number section
before clicking the "Search" button to see if the taxonomy code is available. you will get provider
↙ ↘

specialty under 'Primary Taxonomy' Yes No

Section) ↓ ↓

↓ Would you kindly reprocess? Could you please provide

me with the claim's information, including the claim number and call reference?

↞ accessible upon claim

Is the representative in agreement?

Would you kindly grant me the ↑

claim# and call reference #? reevaluate the assertion Is it the same as CPT?

Yes

\as provider specialty May I have the claim#

↘ ↓ & call ref#?

For reprocessing, what is the turnaround time (TAT)?

Would you kindly provide the claim# and call reference number?

Important Note:
  The taxonomy code for the rendering provider is located in box # 24J above NPI on the CMS 1500
form, and the taxonomy code for the billing provider is located in box # 33b.
 If the representative is unable to locate the taxonomy code in CMS 1500 despite having it
available, they should resubmit the claim as there might be a mistake in the previous submission.
 Should the taxonomy code not be present on the claim form, please resubmit the claim to verify
if the taxonomy code is still present on the form. Inform the same client if it is still missing.

9: The diagnosis is inconsistent with the

patient's age

Situation of On Call:

The claim has been rejected due to the diagnosis code not matching the
patient's age.

MayI have the date of denial?

If there are multiple DX codes coded, could you please tell me which diagnosis
code is invalid?

Check patient payment history if the same

DX code paid with same CPT

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What's the cutoff date for receiving payment
for the same CPT? send corrected claim?

↓ ↓

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

How much is the time limit

to send an appeal?
 ↓

Could you please provide the claim number and call

reference number?

Important Note:
 If the deadline for submitting the corrected claim is not missed, the coding team should be
tasked with reviewing this denial and providing the correct DX code. After receiving a response
with the correct DX details, submit the corrected claim to insurance by updating the DX code.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team determines that the DX code is accurate.
 When filing an appeal, figure out how long the appeal has to be filed from the date of the denial;
if the period has passed, file the appeal; if it has, write off the claim.
 Work in accordance with the client's request, which occasionally requires us to send the appeal
after the deadline has passed.

10: The diagnosis is inconsistent with the

patient's gender
Situation of On Call:

Because the diagnosis code is inconsistent with the patient's gender, the
claim is denied.

MayI have the date of denial?

Should there be more than one DX code coded, could you please let me know
which diagnosis code is inconsistent?

If the patient's payment history shows that the same DX code was paid with the
same CPT, check that information.

↙ ↘

Yes No
 ↓ ↓

Would you kindly process the claim again as How much time does it take to receive
payment for the same CPT? send corrected claim?

↓ ↓

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

What is the duration within which an appeal can be

sent?

Could you please provide the claim number and call

reference number?

Important Note:
 If the deadline for submitting the corrected claim is not missed, the coding team should be
tasked with reviewing this denial and providing the correct DX code.After receiving a response
with the correct DX details, submit the corrected claim to insurance by updating the DX code.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team determines that the DX code is accurate.
 Calculate the time limit from the denial date before filing an appeal. If the time limit is not
exceeded, file the appeal; if it is, write off the claim.
 Work in accordance with the client's requests, which occasionally require us to send the appeal
after the deadline has passed.

11: The diagnosis is inconsistent with the

procedure
Situation of On Call:

Claim rejected because the diagnosis code does not match the procedure

MayI have the date of denial?

 Should there be more than one DX code coded, could you please let me know
which diagnosis code is inconsistent?

If the patient's payment history shows that the same DX code was paid with the
same CPT, check that information.

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What is the deadline for receiving payment
for the same CPT and DX? Please submit the updated claim.

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

How much is the time limit

to send an appeal?

May I have the claim# & call ref#?

Important Notes:
 If the deadline for submitting the corrected claim is not missed, the coding team should be
tasked with reviewing this denial and providing the correct DX code.After receiving a response
with the correct DX details, the corrected claim should be submitted to the insurance by updating
the DX code.
 Work in accordance with the client's request, which occasionally requires us to submit the
updated claim even after the deadline has passed.
 Submit an appeal to insurance if the coding team determines that the DX code is accurate.
 Calculate the time limit from the denial date before filing an appeal. If the time limit is not
exceeded, file the appeal; if it is, write off the claim.
 Work in accordance with the client's request, which occasionally requires us to send the appeal
after the deadline has passed.

13: The date of death precedes the date of

service
Situation of On Call:

Claim rejected because the date of death comes before the date of
service

May I get the denial date?

Could you please provide the date of death?

Verify whether DOS is lying before, on the same day, or after the death date.

↙ ↓ ↘

(Prior to DOD)

(On the Same Day)

(Following DOD)

Would you kindly forward the Would you kindly forward the Could you kindly advise
what can be done to submit a claim back for reprocessing since we have proof that this date of death is
what the DOS is based on and it is not the date that the DOS lies before? the same day as
the demise? service provided on a DOS system?

What is the turnaround time (TAT) for a representative to confirm that the date of death has
been updated in the reprocessing? ↙ ↘ ↗ your system.

↓ Yes No → → ↓

Could you please provide the Claim#? ↑ (Try to work, gather, and call
the reference number. According to the representative's suggestion, what is the TAT
information for reprocessing? However, the representative will most likely request that
you send an appeal.

Would it be possible for me to have the ↑

Claim#& Call ref# together with the claim number and call reference? Which mailing or
fax number should I use to submit an appeal?

↓
 How much is the appeal limit?

Would you please provide the Claim#

and Call ref#?

Important Note:
 This denial happens when the billed DOS is after the date of death, as the denial reason suggests.
Although it may not sound appropriate, improper DOS updating could be the cause of this.
 Therefore, in the event that this denial happens, confirm the date of service using medical
records, and if it has been updated inaccurately, correct it.
 Please proceed with the above scenario if the medical records accurately reflect it.

16: Claim/service lacks information or has

submission/billing error(s)
On Call Situation:

Claim denied as extra data

asked from supplier

May I get the dissent date?

What kind of records have you

asked from supplier?

What is the Fax# or Mailing address

Important Note:
 On the off chance that asked archives are accessible to you at that point send it to protections or
inquire the client on the off chance that reports are not accessible.
  Calculate the time restrain from the refusal date, in the event that it isn't crossed at that point
send the archive, or else type in off the claim in case the time constrain is crossed.
 Now and then the client needs us to send the archive indeed in case the time constrain is
crossed, so work appropriately.
 Continuously check the comment code given with the refusal reason, sometimes it gives the
precise reason for dissent that might vary. So follow the AR situation device to work the precise
refusal.

18: Exact duplicate claim/service

Dissent Event:
 This dissent happens when the same benefit on the same date of benefit is charged more than
once.
 This refusal too happens in case the claim is charged twice in an blunder. In this case, the
primary charging claim gets prepared and the moment one gets denied as copy benefit.

Situation of On Call:

Refused claim due to duplication

Could you please let me know when the application was denied?

Check if CPT of your charge billed

more than once on same DOS

↙ ↘

No Yes

↙ ↓

What is the initial Verify whether the modifier has rendered the provider's
status of the claim. and the exam time on the medical records are the same

↑ It is not applicable to the original claim status.

Go Here Would you kindly reprocess? Could you please provide the
claim since modifier, claim#, and call reference number?

rendering provider or exam time differs in terms of how it is recorded

in medical records?

↓
 Rep concurs?

↙ ↘

Yes No

↙ ↙ ↘

What is the TAT that the representative was asked to ask the representative to
ask the representative to reprocess? submit an appeal submit corrected

Would you please give me the ↑ What is the call reference number
and claim number, or the Fax number? Which mailing address is this?

↓ How much is the

May I have the time limit?

Claim# and Call reference #?

Could you please provide me with the claim

number and call reference?

Important Notes:
 Kindly follow your process update by taking appropriate action. The actions listed below might
differ from your process update.
 Ask for the original claim status and follow the AR Scenario based on the denial reason if the
same CPT is not billed more than once on the same DOS.
 The representative agrees to reprocess the claim and schedule the follow-up for the TAT
provided by the representative if the same CPT is billed more than once on the same DOS and
modifier, rendering provider & exam time on the medical records are different.
 The representative refuses to reprocess the claim and requests that you send a corrected one,
update the correct modifier, and submit the updated claim by updating the correct billing code
"7" and the claim number if the same CPT is billed more than once on the same DOS and
modifier, rendering provider & exam time on the medical records are not the same.
 Add 77 modifiers and resubmit the updated claim if the rendering providers on the charges
differ.
 Add 76 modifiers and resubmit the updated claim when the exam times differ but the providers
on the charges are the same.
 Send an appeal to insurance if, after sending the amended claim, it is once more denied for the
same reason and the insurance representative refuses to reprocess the claim.
 Send an appeal to insurance when the representative refuses to reprocess the claim due to
different charge modifiers.
 Send a new claim to Medicare since they will not accept the updated one.
  The representative refuses to reprocess the claim and requests that you send an appeal to the
insurance company if the same CPT is billed more than once on the same DOS and modifier,
rendering provider & exam time on the medical records are different.
 When submitting an appeal, figure out how long the window of time is from the date of denial;
if it is not exceeded, send the document; if it is, write off the claim.
 Work in accordance with the client's request, which occasionally requires us to send the
document after the deadline has passed.
 The charge should be reversed if the same CPT is billed more than once on the same DOS and
modifier, providing the provider and exam time on the medical records are identical.
 Sometimes, in order to comply with client instructions, the client requests that we seek
clarification from the coding team regarding whether or not these charges are duplicates.

19: This is a work-related injury/illness and

thus the liability of the Worker's
Compensation Carrier
Situation of On Call:

Refusal of claim as Since this is an illness or injury related to the workplace,

the responsibility of

the carrier for workers' compensation

MayI have the date of rejection?

Would you kindly furnish the worker compensation details?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

Could you please tell me the name, policy number, payer number, and mailing address of worker
compensation? claim# and call ref#?

Could you please provide the claim number and call reference number?
Important Note:
 In the event that the representative lacks information about the worker compensation carrier,
ascertain from the system whether any worker compensation insurance is available or whether
the patient's payment history indicates the existence of worker compensation insurance as
primary. If so, determine the patient's eligibility for that insurance and resubmit the claim to the
payer; if not, release the claim to the patient.
 If access to the payer web portal is granted, you may also use it to obtain information about
your WC insurance.
 You can resubmit the claim to primary insurance and update that insurance as primary once the
representative has given you all the worker compensation details. Commercial payer should not
be kept as a backup insurance.
 Medicare can continue to be a secondary insurance plan. After updating the MSP code,
Medicare will be billed when worker's compensation leaves the remaining amount as the
patient's responsibility.

20: This injury/illness is covered by the

liability carrier
Situation of On Call:

Refusal of claim as The liability carrier is responsible for covering this injury
or illness.

MayI have the date of rejection?

Would you kindly furnish the liability carrier details?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

Could you please provide me with the liability carrier's name, policy number, payer ID, and
mailing address? Please provide the reference number.

Could you please provide the claim number and call reference number?
Important Note:
 In the event that the representative lacks the details of the liability carrier, see if the patient's
payment history indicates that liability insurance is primary in the system. If so, submit the claim
again to the payer; if not, release the claim to the patient.
 If access to the payer web portal is permitted, you may also use it to obtain details about liability
insurance.
 You can update that insurance as primary and resubmit the claim to primary insurance once the
representative has given you all the information about the liability carrier. Commercial payer
should not be kept as a backup insurance.
 Medicare can continue to be used as a secondary insurance source. Medicare will be billed after
the MSP code is updated, and the liability carrier will leave the remaining amount as the
patient's responsibility.

21: This injury/illness is the liability of the

no-fault carrier
Situation of On Call:

Refusal of claim as This illness or injury is the responsibility of the No-fault

insurance.

provider/auto insurance

MayI have the date of rejection?

Would you kindly furnish the No-fault carrier/auto insurance details?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

What is the policy id, name, and Could you please provide me with the
payer ID and mailing address for claim# and call reference number?

Auto insurance or no-fault carrier?

 Could you please provide the claim number and call reference number?

Important Note:
 In the event that the representative lacks No-fault or auto carrier information, see if any auto
insurance is available in the system, or if the patient's payment history indicates that auto
insurance is primary. If so, submit the claim again to the payer; if not, release the claim to the
patient.
 If access to the payer web portal is permitted, you may also use it to obtain information about
your auto insurance.
 You can update that insurance as primary and resubmit the claim to primary insurance after the
representative gives you all the information about the No-fault/Auto carrier. Commercial payer
should not be kept as a backup insurance.
 Medicare may continue to be used as a secondary insurance source. Medicare will be billed after
the MSP code is updated when the No-fault or Auto carrier leaves the remaining amount up to
the patient's responsibility.

22: This care may be covered by another

payer per coordination of benefits
Call Scenerio:
Claim rejected because primary payer is another

Could you please let me know when the application was denied?

Canyou tell me which insurance is the primary one?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

Which dates are the effective and term dates of the policy? Could you please provide
the claim number and term? & dial the reference number?

The product
 Representative has the information. Rep lacks specifics.

The product

Was DOS policy in effect? What is the policy id, payer id

↙ ↘ & mailing address of primary

Yes No insurance?

↓ ↓ ↓

What is the situation? Would you kindly I would like the policy ID, payer ID, claim number, and
call reference number to be reprocessed.

& mailing address given that primary primary insurance is not currently active?

protection? What's the turnaround time?

Could you please provide me with the claim# and call reference? Could you please provide the
claim number and call reference?

Important Note:
 In the event that the representative lacks primary insurance information, check in the system to
see if the patient has any other insurance that is available or if the patient's payment history
indicates that another insurance is primary. If so, determine whether the patient is eligible for
that insurance, resubmit the claim to the payer if the policy is active as primary, or release the
claim to the patient if no other insurance information is available.
 If access is granted, you can also check the payer web portal to obtain primary insurance details.
 There's a chance that the primary insurance is inactive on Dos, in which case ask insurance to
reprocess the claim after the representative provides the primary insurance information and you
have access to the primary insurance web portal. Always check your eligibility through the
website.
 You can update the primary insurance as primary, make the current insurance secondary, and
resubmit the claim to the primary insurance once the representative has given you all the
information about the primary insurance.
 Click Here to follow the primary EOB scenario if a claim has already been paid by primary
insurance.

23: The impact of prior payer(s)

adjudication including payments and/or
adjustment
Denial Occurrence:
  When primary insurance already pays more than or equally to the secondary allowable amount,
a denial takes place.
 To better understand when and how secondary insurance pays or refuses to pay the CPT for
denial 23, refer to the examples below.
 Example 1: A $90.00 billed CPT is approved by primary insurance for $20.00, will be paid $16.00,
and the PTR will pay $4.00 in coinsurance. The same CPT is permitted for $20.00 when
secondary insurance processes the same claim; since primary insurance has already paid $16.00,
secondary insurance covers the remaining $4.00.
 Example 2: A $120.00 billed CPT is approved for $30.00 by primary insurance, paid $24.00, and
has a $6.00 coinsurance amount from PTR. After primary insurance has already paid $24.00,
secondary insurance processes the same claim and allows the same CPT for $28.00. Primary
insurance pays the $4.00 and refuses the remaining $2.00 from coinsurance for denial 23.
 Example 3: A $100.00 CPT bill is approved for $25.00 by primary insurance, paid for $20.00, and
the PTR is $5.00 coinsurance. When the secondary insurance processes the same claim, it
determines that the primary insurance has already paid $20.00 and permits the same CPT of
$20.
 You must contact the insurance company to verify the denial reason if you receive a denial 23
from your primary insurance and there is no payment.

Situation of On Call:

Claim rejected since primary payer paid more than the secondary payer's
permitted amount

MayI have the date of denial?

What is the permissible amount?

In the system, what is the amount that is covered by primary insurance?

Does the principal amount paid exceed or remain the same as the secondary
allowed amount?

↙ ↘

Yes No

↓ ↓

Would you please give me the Would you kindly reprocess the claim with
the call reference number and claim number? since primary PA is less than secondary AA?

What is the turnaround time (TAT) for reprocessing?

 Could you please provide the call reference number and
claim number?

Important Note:
 Kindly proceed in accordance with your process update. The actions listed below might differ
from your process update.
 Write off the remaining amount if the primary paid amount exceeds or equals the secondary
allowed amount.
 Set the follow-up for the TAT that the representative provides if the primary paid amount is less
than the secondary allowed amount and the representative consents to reprocess the claim.
 To access Quiz, click this link.

24: Charges are covered under a capitation

agreement/managed care plan
Denial Event:

A payer and a provider enter into a contract known as capitation, under which the payer pays the
provider a set sum of money for each patient over a predetermined length of time, regardless of the
number of services the patient receives. A patient may get many services or few services.

When the patient is covered by the capitation agreement, this denial takes place.

The capitation agreement, which specifies that the claim must be billed to managed care insurance, is
unrelated to this Medicare/Medicaid payer denial.

Fee For Service: Fee for service is a plan where insurance pays each service given by the provider, so it's
the insurance's responsibility to pay each claim.

Situation of On Call:

Claim paid directly to provider under capitation contract; claim rejected because patient
covered by managed care or capitation plan

↙ ↘

For Medicare/Medicaid Payer For Other Payers

↓ ↓
 Could you please let me know when the application was denied? Please provide
the processed and paid date.

↓ ↓

Which payer for managed care What are the Patient, AA, and PA Responsibilities?

is in use on DOS? (Coins, Deductible or Copayment) ↑

Can I obtain a claim mailing and policy ID? Would you please let me know if this patient
has managed care insurance? encompassed by capitation or not?

↓ ↙ ↘

Please provide the Call ref# and Claim #. In the negative Would you kindly forward
Could you please let me know when the capitation contract's start and end dates are for processing
claims back?

since the patient is not covered by the capitation? Check if

DOS lies between

↙ capitation contract start and

What is the TAT for end date

reprocessing? ↙ ↘

↙ No Yes, please provide

the Claim#, Call ref#, and claim number. Would you kindly forward As the DOS does
not lie, may I have the claim back for reprocessing Claim# & Call?

in between the time of capitation?

What is the turnaround time (TAT) for reprocessing?

Could you please provide me with the Claim# and Call

ref#?

Important Reminders & Steps: Kindly follow your process update by taking appropriate action. The
actions listed below might differ from your process update.

You can update the managed care insurance as primary and submit the claim to that insurance if you
receive a denial from Medicare or Medicaid and you have the managed care insurance details, policy ID,
and claim mailing address.

If access to the Medicare/Medicare web portal is permitted, you may also use it to obtain information
about managed care.
With the exception of BCBS payer, managed care insurance can be billed using the same policy ID as
Medicaid insurance in the event that the Medicaid payer denies the claim.

Managed care insurance cannot be billed under the same policy ID as Medicare if the Medicare payer
denies the claim. Need to use their portal or call to find out the correct policy.

Do not designate Medicare or Medicaid as the secondary payer when billing a claim to managed care
insurance as the primary payer. Medicare/Medicaid will not have to pay the claim; instead, they will
continue to reject it with a denial code of 24.

Establish the follow-up for the TAT that the representative provides if they verify that the patient is not
covered by the capitation agreement and consent to reprocess the claim.

Since the claim is processed under the terms of the contract, wherein a fixed amount has been decided
to be paid to the provider, it must be written off if the representative verifies that the patient is covered
under the capitation agreement and the DOS falls within the capitation agreement period.

To access Quiz, click this link.

26: Expenses incurred prior to coverage/27:

Expenses incurred after coverage
terminated
Denial Occurrence:

This type of denial happens when a service is rendered on a date that falls outside of the window
between the policy's effective and expiration dates.

On Call Situation:

Claim denied as part scope

ended or Approach named

May I get the dissent date?

May I have the approach compelling and named date?

Check in the event that DOS lies between viable and named date

Yes No
 ↓ ↓

Would you kindly forward the Exists another policy that allows
for a reimbursement claim for reprocessing that is in effect for patients on DOS?

because the DOS policy is active? ↙ ↘

↓ Absolutely

What is the time interval for reprocessing? Would you please provide
me with the policy ID, the claim number and call reference number, and the policy's effective date?

Could you please provide me with the claim number, call reference number, and term
date? ↓

Would you please provide the claim# and call reference

number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

You should schedule the follow-up for the TAT that the representative provides if they send the claim
back for additional processing.

Resubmitting the claim after updating the new policy ID in case the representative discovers another
active policy on DOS is an option.

You can give the patient their claim back if the policy is dormant and there isn't an active policy on DOS.

Verify whether the patient has access to any other insurance before releasing the claim to them.

If there is another insurance that the patient is eligible for, use the online portal to see if they are
eligible. If they are, set the other insurance as the primary and submit the claim again.

Always verify with the prior DOS whether or not payment from another insurance was received. If so,
verify that payer's eligibility for DOS and, if the patient policy is still in effect, resubmit the claim.

To access Quiz, click this link.

26: Expenses incurred prior to coverage/27:

Expenses incurred after coverage
terminated
Denial Occurrence: This type of denial happens when a service is rendered on a date that falls outside of
the window between the policy's effective and expiration dates.

Situation of On Call:
 Claim rejected as member coverage terminatedor policy terminated

Could you please let me know the date of the denial?

Could you please let me know the policy's effective and expiration dates?

Check if DOS lies between effective and termed date

↙ ↘

Yes No

↓ ↓

Would you kindly provide the Is there another policy that allows
for a claim back for reprocessing that is in effect for patients on DOS?

as of the policy's activation on DOS? Yeah, but

What is the time interval for reprocessing? Please provide me with the
policy ID, the claim number and call reference number, and the policy's effective date.

Could you please provide me with the Claim# and the term date?

& Contact reference number?

Would you please provide me with the claim# and call

reference number?

Important Reminders & Step:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

You should schedule the follow-up for the TAT that the representative provides if they send the claim
back for additional processing.

Resubmitting the claim after updating the new policy ID in case the representative discovers another
active policy on DOS is an option.

You can give the patient their claim back if the policy is dormant and there isn't an active policy on DOS.

Verify whether the patient has access to any other insurance before releasing the claim to them.

If there is another insurance that the patient is eligible for, use the online portal to see if they are
eligible. If they are, set the other insurance as the primary and submit the claim again.

Always verify with the prior DOS whether or not payment from another insurance was received. If so,
verify that payer's eligibility for DOS and, if the patient policy is still in effect, resubmit the claim.

To access Quiz, click this link.

29: The time limit for filing has expired
Denial Occurrence:

This type of denial happens when a claim is received by insurance after the TFL has expired.

TFL:

The acronym for timely filing limit is TFL.

An insurance company's timely filing limit is a deadline that providers must meet in order to file a claim.

The date of service (DOS) is the starting point for computing TFL.

POTF:

Proof of timely filing is what POTF stands for.

The following proofs can be regarded as POTF.

an initial claim that was submitted to the same insurance but was rejected by the payer.

At first, claims were rejected.

first invoice to any additional payer.

AFL:

The acronym for appeal filing limit is AFL.

It is necessary to compute ATL starting on the denial date (DOD).

Situation of On Call:

Claim denied as Past timely

filing or TFL expired

May I get the denial date?

When was the claim received?

What is the amount of the Timely filing limit?

Check if the claim was received within TFL

 ↙ ↘

Yes No

↓ ↓

Could you please send the Check if POTF available

claim back for reprocessing ↙ ↘

since the claim was received Yes No

within TFL? ↓ ↓

↓ Can we use POTF to appeal? Could I please have

How long does it take to reprocess? ↓ the claim# &

↓ What is the mailing call reference number or fax number?

Could you please provide the claim number and address so that I can submit an appeal? & call
reference number? What is the appeal limit?

May I have the claim# &

call ref#?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

You can schedule a follow-up for the TAT that the representative provided if the claim was wrongfully
denied and the representative sent it back for reprocessing.

Submit an appeal to the insurance company if the claim was billed after TFL expired and there is proof of
completion (POTF) showing that the claim was billed within TFL.

You can modify the claim if it was billed after TFL expired and no POTF is available.

assert.

If a claim was originally billed within TFL to a different insurance and then billed to your current
insurance after TFL expired, you can use the original billing information as POTF and file an appeal with
the insurance company.

Determine the appeal filing limit. If it hasn't been exceeded, send the POTF; if it has, write off the claim.

Work in accordance with the client's request to send POTF even when the AFL is crossed.
Another situation you might encounter is one in which the claim was billed to insurance on the last day
of the TFL period, but the insurance did not receive the claim until after the TFL had ended (for instance,
if the TFL is 90 days, and the claim was billed to insurance on the 90th day, but the insurance did not
receive the claim until the 91st day or later). To get the money, you can then file an appeal on such
claims using POTF.

To access Quiz, click this link.

31: Patient cannot be identified as our

insured
Denial Occurrence:

The occurrence of a denial happens when a patient's name, date of birth, or gender is entered
incorrectly on a bill.

On Call Scenario:

The patient's identity is unknown

Would you kindly search the patient using the following information: Name,
DOB, or Social Security number?

If the representative locates the patient In the event that the

representative is unable to locate the patient

Could I please have the right policy ID? Could you please give me the
call reference number?

Could you please check if claim

is available for the DOS with correct

member ID?

↙ ↘

Yes No

↓ ↘

Observe the AR Scenario Could I please have the tool that is applicable to my claim
status and the policy's term date?

Click Here to See More

Verify whether the DOS is between the effective and term date of

In the negative
 ↑

↑ Could you please provide me with the call reference number? May
I have the Timely

filing limit(TFL)?

Verify the DOS is located within TFL

Yes No

↙ ↓

Could I please make a claim? Would it be possible for us

to fax or mail the mailing address, claim, and POTF together with the invoice?

Payer ID and Fax#? ↖ ↙ ↘

↓ ← No Yes, please. Could I

please have my call reference number?

May I have Fax#

or Mailing address

to send claim along

with POTF?

Could you please give me the

call reference number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

If the patient has no other active insurance and the representative is unable to locate them, the claim
may be released to them.

If access to the insurance portal is available, check it before releasing the claim to the patient so that the
patient's information is confirmed.

Always verify with the prior DOS whether or not payment from another insurance was received. If so,
verify that payer's eligibility for DOS and, if the patient policy is still in effect, resubmit the claim.

Following the Name, DOB, and SSN search, if the representative finds the patient and the claim,
proceed with the AR scenario based on the claim's status.
In the event that the patient's policy is not active on DOS and the representative locates the patient but
not the claim, the patient may be released from the claim provided they have no other active insurance.

You can resubmit the claim if the representative locates the patient but not the claim, the payer ID and
mailing address match the system details, the patient policy is active on DOS, and DOS is located within
TFL.

Resubmit the claim if the representative finds the patient but not the claim, the patient policy is active
on DOS, DOS has crossed the TFL, and the representative confirms that you are unable to fax or mail the
claim along with POTF. After receiving a TFL denial, you can use POTF to file an appeal.

In the event that the representative locates the patient but not the claim, the patient policy is active on
DOS, DOS has crossed the TFL, and the representative validates that you can fax or mail the claim along
with POTF, then do so. (The client may prefer to resubmit the claim rather than send the appeal after
TFL denies and waiting to mail or fax the claim with POTF. Thus, follow the directions.)

The claim must be written off if the representative locates the patient but not the claim, there is no
POTF, and the claim was billed after TFL was crossed.

Medicare will not process an application if the policy ID, name, and date of birth on the ID card are
incorrect. This is because Medicare cannot identify the patient. The format of Medicare policy is now
MBI instead of HIC. Both have 11 characters, but MBI has 11 characters in an alpha-numeric format and
the HIC number has a suffix at the end of the SSN.

To learn more about MBI, go here.

You can use the web portal to look up the correct last and first name if you have an MBI number but
your ID was denied by Medicare due to a patient name problem. Occasionally, first and last names are
swapped out. Adding Jr, Sr, I, II, III, and IV to the last name is another way you can attempt to draw the
patient.

Never billed Medicare ID denial to supplemental plan because they would refuse the claim on the
grounds that the primary insurance company had rejected it, meaning the claim would not be
processed.

A three-character alpha prefix is part of the BCBS policy format. If the claim is billed without this prefix,
it will be denied for an unidentified patient. These prefixes are state-based, and if you know the
patient's Social Security Number (SSN), you can pull up the patient on the Availity web portal. This
method isn't always reliable, but it can be done occasionally. For the state of New Mexico, for instance,
use YIF or XIF, then SSN. Use XYL, then SSN, etc. for the MI state. In a similar vein, you can use SSN to
find the prefix details for the state you are working in.

To access Quiz, click this link.

How to wok on denial code - 45

45:
Fee schedule/maximum permitted/contractual/legislated fee arrangement is exceeded by the charge.

CO-45:

This denial happens when the charge or CPT exceeds the maximum amount permitted or the fee
schedule, as stated in the description.

Fee schedule: It specifies the total amount that must be paid to a CPT.

The provider adjustment amount is typically the amount that is rejected for CO-45, though this can vary
depending on the circumstances. The scenarios where CO-45 denial happens are listed below; you can
work on each scenario by following the instructions.

1. Upon processing and payment of the claim OR upon processing the claim and applying it to the
patient's obligation (deductible, coinsurance, and copayment).

In this case, the adjustment amount is the amount that is rejected for CO-45. If you have the authority,
you can easily change this amount.

2. When the claim is rejected and the EOB lists several reasons for the denial.

In this case, you can just work on resolving the claim by ignoring the CO-45 denial and addressing the
other denials.

3. When the claim is rejected and CO-45 is the only reason for the denial.

In this case, you will have to give the insurance company a call to find out the precise rationale behind
the denial and proceed appropriately. (Never assume that this represents an adjustment.)

PR-45:

Occasionally, PR-45 denial will appear in place of CO-45 denial. You can still work on PR-45 using the
aforementioned scenarios, but the patient is responsible for any money that is rejected.

Don't charge the patient directly for the PR-45 amount. Upon receiving confirmation from your client,
proceed as necessary.

Most often, it happens when the provider is not in the network.

49: This is a non-covered service because it

is a routine/preventive exam or a
diagnostic/screening procedure done in
conjunction with a routine/preventive exam
Cause of Occurrence:

When a claim is billed for a standard diagnosis, this denial takes place.
Routine diagnosis codes are those that begin with "Z."

If a different appropriate diagnosis code is substituted for the routine diagnosis, this can be fixed.

Scene of On Call:

Claim rejected because regular services are not covered

Could you please let me know the date of the denial?

How long does it take to submit a revised claim?

What is the mailing address or fax number for submitting an appeal?

How long is the deadline for sending an appeal?

Could you please give me the claim number and call reference?

Important Note:

If the deadline for submitting the corrected claim is not missed, the coding team should be tasked with
reviewing this denial and providing the correct DX code.After receiving a response with the correct DX
details, submit the corrected claim to insurance by updating the DX code.

Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Routine services are not covered by the patient plan and are the patient's responsibility; if the coding
team certifies that the DX code is correct, bill the claim to the patient or secondary payer.

It is necessary to confirm the patient's eligibility for a secondary or consecutive payer before billing the
claim to one of these payers.

If access is available, check the payer website to confirm the eligibility of a secondary or consecutive
payer; if not, contact the insurance provider.

Bill the claim if a patient policy is in effect for secondary or subsequent payers on DOS.

The patient will receive the claim if no other payer is available or active on DOS.

Depending on the situation, the client may request that we submit an appeal to the insurance company
rather than giving the patient access.

Calculate the time limit from the denial date before filing an appeal. If the time limit is not exceeded, file
the appeal; if it is, write off the claim.

Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.
50: These are non-covered services
because this is not deemed a 'medical
necessity' by the payer
Situation of On Call:

Claim denied as medically not necessity

May I get the denial date?

Why is it not medically necessary?

Check patient payment history if the same

DX code paid with same CPT

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What is the deadline for receiving payment
for the same CPT and DX? send corrected claim?

↓ ↓

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

What is the duration within which an appeal can be

sent?

Could you please provide the claim number and call

reference number?

Important Note:

If the deadline for submitting the corrected claim is not missed, the coding team should be tasked with
reviewing this denial and providing the correct DX code.After receiving a response with the correct DX
details, submit the corrected claim to insurance by updating the DX code.
Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Submit an appeal to insurance if the coding team determines that the DX code is accurate.

Calculate the time limit from the denial date before filing an appeal. If the time limit is not exceeded, file
the appeal; if it is, write off the claim.

Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.

55: Procedure/treatment/drug is deemed

experimental/investigational by the payer
Situation of On Call:

Claim denied because procedure, treatment, or medication is considered

experimental or investigative by the payer

(If the same CPT is covered by the same insurance, review the payment history
of that insurance)

↙ ↘

Yes No

↓ ↓

Would you kindly reprocess the claim as follows: Do you require any further payment received for
the same CPT? paperwork needed to handle the claim?

What is the turnaround time (TAT) for reprocessing? ↑ Which

document What is the mailing address or fax number? Could you please let me know what is
required? address where an appeal can be sent?

claim# and call reference number? The product

What is the amount of the time limit for sending the document?
a request for help?

The product

Could I please have the claim# and call reference number?

Important Note:
It can occasionally be quite challenging to get the CPT reimbursed for this denial. Therefore, the task of
obtaining a different CPT code ought to fall to the coding team.

Update the CPT code and resubmit the claim if the coding team offers an alternative.

Work according to the representative's recommendation if the coding team responds that there isn't a
different CPT code. Please share any additional documents that the insurance may require.

You can try an appeal if the insurance company does not require any more documentation.

Sharing these CPTs with the client is also beneficial because occasionally they have information on
whether or not the insurance will cover the CPTs. Additionally, if the CPT refuses to pay, they advise
writing off the CPT directly rather than submitting more paperwork or filing an appeal.

58: Treatment was deemed by the payer to

have been rendered in an inappropriate or
invalid place of service

Situation of On Call:

Claim denied for invalid place of service

May I get the denial date ?

Would you kindly let me know the proper location for the service?

↙ ↘

If rep provides If rep refuses to provide

↓ ↓

What is the deadline for Would you kindly verify and submit the
updated claim? Is there a paid hospital claim associated with the same DOS?

Could I please have the claim# and call reference number? No

Yes

↓ ↓
 What is the deadline? ← What is the point of sale (POS) in
order to submit a corrected claim? the hospital's assertion?

Could you please give me the call reference number and claim
number?

Important Note:

Update the POS and send the corrected version to insurance if the representative provides the accurate
version. Always submit new claims to Medicare as they will be accepted, even if the claim has been
corrected.

Assign the claim to the coding team so they can examine it and supply the correct POS if the
representative fails to supply the correct one.

Work accordingly after you hear back from the coding team. If the representative disagrees, get the
details for the appeal and submit an appeal to the insurance company. If the response regarding the
coding is accurate, call the insurance company and attempt to reprocess the claim.

96: Non-Covered Charges

Denial Occurrences:

There are two categories for this denial:

Uncovered expenses according to the patient's plan

charges that are not covered by the provider contract

Charges that are not covered by the patient plan:

The following causes of this denial: Provider is not connected to the network

DX or ICD-10 code that is not covered by patient policy

CPT code that is not covered by patient policy

Charges that are not covered by the provider contract:

When the CPT code is not covered by the provider contract, this denial happens.

Situation of On Call:

Claim rejected due to Non-Covered Charges

Could you please let me know when the application was denied?

Does the patient plan or provider contract not cover it?

↙ ↘

Not covered by the patient plan Not covered by provider contract

 For what reason is it not covered? For what reason is it not covered?

↙ ↓ ↘ ↙ ↘

The provider is either DX or ICD-10; other; CPT is not covered under; other; out-of-network; not
covered; provider contract; other reasons

↓ ↓ ↓ ↓ To Follow AR, Click This

What is the procedure to check payment history using the scenario tool? How long does it take to
receive the payment if it is received for the same? Go Here

submit the CPT and claim number from the amended claim to the same provider?
call the reference number? same insurance

↓ ↙ ↘

May I have the Yes No

Claim# & Call ↓ ↓

ref#? Would you kindly submit the claim? What is the Appeal number or
fax number, and how can I send an appeal back for reprocessing since the address provided?

We have been paid for the same procedure. How much is the
appeal limit?

↓ ↓

Rep Agrees? Could I please have the claim# and call

reference number?

Yes No

↙ ↘

What's the TAT? Could you please explain what fax# or Appeal means
for reprocessing? Where should I send the appeal?

Would you please give me the What is the appeal limit in dollars?

Claim# and call reference number?

Important Notes:

Kindly proceed in accordance with your process update. The actions listed below might differ from your
process update.

Click the link to follow the provider's out-of-network scenario if the claim is rejected on the grounds that
the provider is not in network and the charges are not covered by the patient plan.

The claim should be sent to the coding team for an alternate diagnosis code if it is rejected on the
grounds that the DX or ICD-10 code is not covered by the patient plan.
Update it and submit a revised claim if the coding team offers an alternate code.

Bill the claim to the secondary or consecutive payer, if available, or release it to the patient if the coding
team is unable to provide an alternate code.

Bill the claim to the secondary or consecutive payer, if available, or release it to the patient if the claim
is rejected for reasons other than non-covered charges under the patient plan.

The patient's eligibility for the secondary or consecutive payer must be confirmed before billing the
claim to that payer.

If access to the payer website is available, use it to confirm the eligibility of secondary or consecutive
payers; if not, contact the insurance provider.

Release the claim to the patient if there isn't another payer on DOS that is active or accessible.

Submit an insurance appeal if the claim is rejected on the grounds that the charges are not covered by
the provider contract, even though the payment appears in the payment history, and the representative
refuses to reprocess the claim.

You have two options if the claim is rejected on the grounds that it contains non-covered charges as per
the provider contract and the payment hasn't been recorded in the payment history: file an appeal or
write the claim off. Thus, follow the directions provided by your client.

Use the scenario tool based on the reason for the denial, as non-covered due to provider plan denial
may not always have the CPT issue or may be different.

If this denial comes from Mississippi Medicaid, click here.

To access Quiz, click this link.

97: The benefit for this service is included

in the payment/allowance for another
service/procedure that has already been
adjudicated
Situation of On Call:

Refused claim because bundle/inclusive

Could you please let me know when the application was

denied?

What is the deadline for sending a corrected claim?

 Could you please provide the mailing address or fax number for me to send an
appeal?

Could you please provide the call reference number and claim number?

Important Note:

The coding team should be notified of this denial in order to determine whether or not the claim can be
resubmitted by updating the modifier.

You can also verify the NCCI edit between procedures if you have access to the encoder, findacode, etc.
tools. You can use these tools to determine whether or not there is an NCCI edit between CPTs that are
billed on the same DOS. If so, whether or not it can be overridden by applying the proper modifier.
Additionally, it offers the best modifier to override the CPT. CPT should be written off if it cannot be
overridden.

Update it and send the updated claim to insurance if the coding team's response includes the correct
modifier, or if you find the correct modifier using any tools. Send a new claim to Medicare since they will
not accept the amended one.

Call the insurance and request that the claim be reprocessed if the coding team's response indicates
that the coding is correct or if you discover that there isn't an NCCI edit using any tools. Send an appeal
to insurance if they reject.

Resources to Determine Bundle CPT Codes

100: Payment made to

Patient/Insured/Responsible party
Denial Occurrences:

This type of denial happens when the patient refuses to sign the Assignment of Benefit (AOB).

When a patient plan covers out-of-network benefits but the provider is not, this denial may also happen.

In the event of an on-call scenario, the claim would be paid to the patient.

What is the processed & paid date?

What are the allowed amount, paid amount and

patient responsibility (Coins, Deductible or Co-payment)?

↓
 Check that the total of Patient Responsibility (PTR) and PA equals AA; if not,
question the representative and obtain the relevant data.

To verify payment details, click this link. ↑

Why was the patient compensated for the claim?

Could you please provide the claim number and call reference?

Important Reminders & Steps:

Kindly proceed in accordance with your process update. The actions listed below might differ from your
process update.

The patient may receive a direct bill from the claim if it is paid to them.

This denial is the patient's responsibility; do not bill the secondary or subsequent payer.

Since the provider is not paid and cannot track it, there is no need to request check details.

To access Quiz, click this link.

109: Claim/service not covered by this

payer/contractor. You must send the
claim/service to the correct
payer/contractor
On Call Scenerio:

Claim rejected because primary payer is another

Could you please let me know when the application was denied?

Would you kindly inform me which insurance is the primary insurance?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

What is the effective & May I have the claim#

termed date of the policy? & dial the reference number?

Representative is in possession of the information. The representative lacks

information.
 Was DOS policy in effect? What are the payer ID, policy id, and mailing address of the primary
insurance policy?

↓ ↓ ↓

What is the situation? Would you kindly I would like the policy ID, payer ID, claim number, and
call reference number to be reprocessed.

& mailing address, as there isn't any active primary insurance? What's the turnaround
time?

Could you please provide me with the claim# and call reference? Could you please provide the
claim number and call reference?

Important Information

: In the event that the representative lacks primary insurance information, check in the system to see if
the patient has any other insurance that is available or if the patient's payment history indicates that
another insurance is primary. If so, determine whether the patient is eligible for that insurance,
resubmit the claim to the payer if the policy is active as primary, or release the claim to the patient if no
other insurance information is available.

If access is granted, you can also check the payer web portal to obtain primary insurance details.

There's a chance that the primary insurance is inactive on Dos, in which case ask insurance to reprocess
the claim after the representative provides the primary insurance information and you have access to
the primary insurance web portal. Always check your eligibility through the website.

You can update the primary insurance as primary, make the current insurance secondary, and resubmit
the claim to the primary insurance once the representative has given you all the information about the
primary insurance.

Click Here to follow the primary EOB scenario if the claim has already been paid by the primary
insurance.

How to work on denial code - 129 (Prior

processing information appears incorrect)
Usually, secondary insurance (or tertiary insurance) denies this claim for the two reasons listed below.

1. The claim is not paid by primary insurance.

2. The secondary payer receives a bill from the primary insurance, but the payment details on the claim
form are inaccurate.

Claim not paid by primary insurance: When a claim is correctly processed by primary insurance,
payment is made by the secondary payer. For instance, if primary insurance processes a claim that is
approved for $100, paid for $80, and has a $20 PTR, secondary insurance is in charge of handling the $20
PTR.

However, this denial happens if the primary insurance company rejects the claim and sends it to the
secondary payer. In this case, you must address the primary insurance company's denial first.

Certain denials, such as non-covered charges according to the patient plan (or all PR denials), are
reimbursed by secondary insurance. Depending on the policy benefit, secondary insurance may or may
not pay the claim when primary insurance makes these denials.

When billed to the secondary payer, the primary insurance has paid, but the payment details on the
claim form are inaccurate:

Always verify the claim form to see if the primary payment information was correctly forwarded to
secondary insurance, even if primary insurance has paid the claim correctly but you have still received
this denial.

This data is available at locator #54 on the UB-04 form and box # 29 on the CMS form.

You can resubmit the claim if the payment details are missing, but make sure to use the most recent
version of the claim form. It is correct if the payment details are printing correctly at this point.
However, if it's still missing, submit the claim by mail or fax.

140: Patient/Insured health identification

number and name do not match
Situation of On Call:

Patient's identity is unknown

Is it possible for you to search for the patient using their name, date of
birth, or social security number?

↙ ↘

If the representative locates the patient In the event that the

representative is unable to locate the patient

Would you kindly verify if claim Could you please provide me with
the call reference number that is available for the DOS along with the correct member ID?

↙ ↘

Yes No

↓ ↘
 Observe the AR Scenario Could you please provide me with the correct policy ID, tool
according to the claim status, patient name, and patient DOB?

Click Here for More Information

Could you please tell me the policy's effective and term dates?

Check if DOS lies between

effective and termed date

↙ ↘

No Yes

↓ ↓

Could you please give me the call reference number? May I

have the Timely

filing limit(TFL)?

Check DOS lies within TFL

↙ ↘

Yes No

↙ ↓

Could I please make a claim? Is it possible for us to fax or

mail the mailing address, claim, and POTF together with the claims information?

Payer ID and Fax#? ↖ ↙ ↘

↓ ← No Indeed.

Could you please provide me with the call reference number? ↑

May I have Fax#

or Mailing address

to send claim along

with POTF?

↓
 Could you please give me the
call reference number?

Important Note:

If the patient has no other active insurance, this denial may be released.

If access to the insurance portal is available, check it before releasing the claim to the patient so that the
patient's information is confirmed.

Always verify with the prior DOS whether or not payment from another insurance was received. If so,
verify that payer's eligibility for DOS and, if the patient policy is still in effect, resubmit the claim.

Medicare will not process an application if the policy ID, name, and date of birth on the ID card are
incorrect. This is because Medicare cannot identify the patient. The format of Medicare policy is now
MBI instead of HIC. Both have 11 characters, but MBI has 11 characters in an alpha-numeric format and
the HIC number has a suffix at the end of the SSN.

To check MBI, click this link.

You can use the web portal to look up the correct last and first name if you have an MBI number but
your ID was denied by Medicare due to a patient name problem. Occasionally, first and last names are
swapped out. Adding Jr, Sr, I, II, III, and IV to the last name is another way you can attempt to draw the
patient.

Never billed a supplemental plan for a Medicare ID denial because the plan would reject the claim and
say it was denied by the primary insurance, meaning it wouldn't be processed.

A three-character alpha prefix is part of the BCBS policy format. If the claim is billed without this prefix,
it will be denied for an unidentified patient. These prefixes are state-based, and if you know the
patient's Social Security Number (SSN), you can pull up the patient on the Availity web portal. This
method isn't always reliable, but it can be done occasionally. For the state of New Mexico, for instance,
use YIF or XIF, then SSN. Use XYL, then SSN, etc. for the MI state. In a similar vein, you can use SSN to
find the prefix details for the state you are working in.

After searching for the patient's name, date of birth, and SSN, the representative typically finds the
patient but is unable to locate any claims because the claim was never billed accurately. Update the
accurate data and resubmit the claim in such a case.

146: Diagnosis was invalid for the date(s)

of service reported
Situation of On Call:
 The claim has been rejected due to the diagnosis code being invalid for the
date of service.

MayI have the date of denial?

If there are multiple DX codes coded, could you please tell me which diagnosis
code is invalid?

Check patient payment history if the same

DX code paid with same CPT

↙ ↘

Yes No

↓ ↓

Could you please reprocess the claim and let me know when payment for the same CPT and DX
must be received? send corrected claim?

↓ ↓

How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

What is the duration within which an appeal can be

sent?

Could you please provide the claim number and call

reference number?

Important Note:

If the deadline for submitting the corrected claim is not missed, the coding team should be tasked with
reviewing this denial and providing the correct DX code.After receiving a response with the correct DX
details, submit the corrected claim to insurance by updating the DX code.

Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Submit an appeal to insurance if the coding team determines that the DX code is accurate.

Calculate the time limit from the denial date before filing an appeal. If the time limit is not exceeded, file
the appeal; if it is, write off the claim.
Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.

150: Payer deems the information

submitted does not support this level of
service
Denial Occurrences:

There are three main reasons why this denial may occur: 1. CPT has exceeded the maximum allowance
for the given time period.

2. Coding error/medically unnecessary.

3. Request for Medical Records.

When working on this denial, make sure to always check the remark code. Occasionally, the proper
denial reason is provided by the remark code.

Situation of On Call:

Claim denied as payers deems the information

submitted does not support this level of service

May I know the exact issue?

The following: ↙

The maximum allowance for a coding issue has been reached by CPT. This means that requests
for a specific time period will no longer be accepted. Go Here Go
Here

Go Here

Important Information:

To follow a particular scenario, click the link.

151: Payment adjusted because the payer

deems the information submitted does not
support this many/frequency of services
Situation of On Call:
 Claim rejected because CPT has reached the maximum allowance for a
particular time period.

Could you please let me know when the application was denied?

Would you please tell me the CPT reimbursement guidelines?

(For instance, CPT is permitted once, twice, etc.)

Determine whether the insurance company has correctly denied the claim based on
the aforementioned guidelines.

(For instance, if the insurance representative certifies that CPT is permitted to pay once
daily, you must verify in your system whether or not the same CPT code has already been paid on the
same day. The denial is valid if the CPT is already paid onthe same day; if not, you will not be able to find
the same CPT on

Denied Incorrectly Denied Incorrectly

↓ ↓

What is the deadline for If possible, could you send the updated
claim? return the claim for reprocessing

What is the mailing address or fax number for the maximum amount allowed?

Where can I send an appeal? What's the TAT?

To what extent is the reprocessing time limit determined by this?

to submit a request for appeal? Could I please have

the claim#, call ref#, claim# & call ref#?

Important Note:

It's possible that a specific charge hasn't been posted in your system or that it was billed by a different
physician at the same facility if you are unable to locate the CPT in the system but the insurance
representative confirms that the same CPT has already been paid according to their records. In this case,
request the CPT information along with the doctor's name, note it in your notes, and appropriately mark
it as denied.

If the claim is properly denied, proceed with the action by adhering to your client's update. One course
of action would be to write off the claim or file an appeal.
163: Attachment/other documentation
referenced on the claim was not received
Call Scenerio:

Claim denied for primary EOB

May I get the denial date?

Verify your system to see if the insurance you called about is classified as primary or
secondary.

↙ ↘

Primary Insurance Option 2: Secondary Insurance

Would you kindly let me know which insurance is primary and whether payments from it are
considered primary insurance? Insurance is received and processed by primary and can be
billed to secondary representatives, what is the process? ↙ ↘

↙ ↘ Yes No

Yes No ↙ ↘

↓ ↓ In the CMS, check box # 29. Consult the principal

Which policy is it? If the insurance and work claim amount is paid, could I please have the 1500 form
with the payer ID, claim number, and call reference?

According to the primary mailing address, primary insurance is available. If this is the case, what does
that indicate about the status of primary insurance?

primary paid details have already been sent to insurance

Would you please give me the claim or call refrence?

Yes No

↙ ↘

Please reprocess the claim if possible. What is the Fax number or mailing
address, given that the primary payment details have already been provided along with the time limit
for sending the claim form in box # 29? forward the EOB?

↙ ↘ ↓

If the representative continues to say it Representative returned the claim. Could

I please have the not received for reprocessing claim# and call reference number?
 Please provide the Fax number or mailing address, the time of the reprocessing, and the TAT.

limit to send the EOB? Could I please have the claim# and call reference
number?

Important Note:

In the event that the representative fails to provide primary insurance information, the system will be
checked to see if the patient has any other insurance that is available or that has been paid for in the
past. If so, eligibility for that insurance will be verified, and the claim will either be released to the
patient if the policy is active and primary or resubmitted to the payer if it is not.

If access is permitted, you can also check the payer web portal to obtain primary insurance details.

There's a chance that the primary insurance is inactive on Dos, in which case ask insurance to reprocess
the claim after the representative provides the primary insurance information and you have access to
the primary insurance web portal. Always check your eligibility through the website.

You can update the primary insurance as primary, make the current insurance secondary, and resubmit
the claim to the primary insurance once the representative has given you all the information about the
primary insurance.

If the primary EOB submission deadline has already passed, write off the expense or adhere to your
client's instructions.

Always verify the comment code provided along with the denial reason; occasionally, it gives the precise
reason for denial, which may vary. In order to work out the precise denial, use the AR scenario tool.

181: Procedure code was invalid on the

date of service
Situation of On Call:

Request denied due to Procedure code being invalid on the date of service

Check insurance payment history if

the same CPT paid by same insurance

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What's the cutoff date for receiving
payment for the same CPT? Please submit the updated claim.
 How long does it take to reprocess? What is the mailing or fax number for an appeal?

Could you please provide the claim number and call reference number? ↓

How much is the time limit

to send an appeal?

Could you please provide the claim number and call

reference number?

Important Note:

If the deadline for submitting the corrected claim is not missed, the coding team should be tasked with
reviewing this denial and providing the proper procedure code.After receiving a response with the
correct CPT details, the corrected claim should be submitted to insurance by updating the correct CPT
code.

Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Submit an appeal to insurance if the coding team certifies that the procedure code is coded accurately.
Determine the time limit from the denial date before sending an appeal. If it hasn't passed, send the
appeal; if it has, write off the claim.

Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.

invalid codes for new patientsor existing patients

182: Procedure modifier was invalid on the

date of service
Situation of On Call:

Claim denied as procedure modifier

was invalid on the date of service

May I get the denial date?

Check patient payment history if the same

CPT code paid with the same modifier

 ↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again as What is the deadline for receiving
payment for the same CPT and modifier? Please submit the updated claim.

How long does it take to reprocess? What is the mailing or fax number for an
appeal?

Could you please provide the claim number and call reference number?
↓

What is the duration within which an appeal can be

sent?

Could you please provide the claim number and call

reference number?

Important Note:

If the deadline for submitting the corrected claim has passed, the corrected claim should be submitted
to insurance by updating the correct modifier. This denial should be assigned to the coding team for
review and provision of the correct modifier. After receiving a response with the correct modifier
details, submit the corrected claim to insurance.

Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Submit an appeal to insurance if the coding team determines that the modifier is accurate.

Determine the time limit from the denial date before sending an appeal. If it hasn't passed, send the
appeal; if it has, write off the claim.

Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.

In the event that the same CPT is billed with two different modifiers (LT and RT), one of which has
already been paid for, and the other is rejected as invalid, insurance must send the CPT in a single line
using the bilateral modifier (50). In order to double the charge amount, voide both CPTs, create a new
line with a 50 modifier, and submit the updated claim to the insurance.

Send the void claim for paid CPT to insurance first, then send a new claim with a 50 modifier since
Medicare will not accept the amended claim.

183: The referring provider is not eligible to

refer the service billed
Situation of On Call:

Claim rejected because referring provider is ineligible to refer the billed

service.

Could you please let me know when the application was rejected?

If you have received payment from the same referring provider, review your
insurance payment history.

Yes No

↙ ↓

Would you kindly process the claim again for payment? Why does the same referring provider's
referral get lost in the mail? able to recommend the billed services?

How long does it take to reprocess? recommending supplier recommending supplier Kindly
provide the claim number and call reference number. on the claim form, which is distinct from the
insurance

↙ ↓ or Group

Verify the claim form if Look up the specialty of the referring provider
to see if any information is available. Could you please provide me with the claim# and call reference
number from the NPPES website?

Yes No ↓

↙ ↓ Verify whether it has the same

Would you kindly reprocess? Could you please provide me with the specialty listed on the CPT
claim along with the claim number and call reference? available on the claim form, billed?
The product ↓ Yes
No

Rep Agrees? ↓ ↓

↙ ↘ Would you kindly reprocess? Would you please grant me

the yes? No, the claim since referring claim# and call ref#?

What's the TAT? Could you please refer this service to me?

for further processing? claim# and call ref#? What is the

turnaround time (TAT) for granting me access to the reprocessing?

claim# and call ref#?

 Could you please provide the claim# and call reference
number?

Important Note:

In the event that the referring provider is not enrolled in insurance or a group, request that the client
complete the enrollment process or provide the next step.

If the specialty of the referring provider differs, request the correct referring provider information from
the client or take other appropriate action. If the details of other referring providers are not available,
modify the claim.

The referring provider's name and NPI will be shown in boxes 17 and 17b of the CMS 1500 form,
respectively.

Information may be missing owing to an error when referring provider information is available in CMS
1500 and the representative resubmits the claim after failing to locate it on their end.

Resubmit the claim if the referring provider's information is no longer available on the form to verify if
the information is still there. Let the customer know if it's still missing.

If this Medicare insurance denial is displayed, click here.

185: The rendering provider is not eligible

to perform the service billed
Situation of On Call:

Claim denied because rendering provider is not qualified to perform the

service for which payment was made. ↑

Check insurance payment history if payment

from same rendering provider received

↙ ↘

Yes No

↙ ↓

Would you kindly reprocess the claim and ask why the rendering provider isn't getting paid for the
same rendering provider? Can I refer the billed services to someone else?

How long does it take to reprocess? rendering service supplier Rendering provider ↑Other
Reasons ↑
 Could you please provide the claim number and call reference number? on the claim form with the
group or may I please have the insurance claim number and call reference?

If information is available, check the claim form. Has the rendering provider ever
enrolled with a group or insurance?

Yes No ↙ ↘

↙ ↓ Absolutely

Would you kindly reprocess? Could you please provide me with the claim number and call
reference number as well as the claim information? Could I please have the efficient Could I please
have access to the available claim form? & the claim number and call
reference number's term?

Is the Representative in Agreement? Could I please have the

claim# and call reference#?

What's the TAT? Please give it to me for reprocessing. claim# and call reference#?

Could you please provide the claim number and call reference number?

Important Note: In the event that the rendering provider is not enrolled with the insurance or group,
request that the client complete the enrollment process or provide the next action.

Give the client a reason and request the next step if the rendering provider is unable to complete the
specific procedure code.

The rendering provider's name and NPI can be found in boxes 24J and 30 of the CMS 1500 form,
respectively.

If the representative is still unable to locate the rendering provider information in CMS 1500 after
resubmitting the claim, there may be a mistake causing the information to be missing.

Resubmit the claim if the rendering provider information is no longer available on the form to verify if
the information is still there. Inform the same client if it is still missing.

197:
Precertification/Authorization/Notification/P
re-treatment absent
Denial Occurrence: When authorization is not obtained for a service or treatment that calls for
authorization, a denial takes place.

The authorization number is located on Locator #63 on the UB04 form or Box # 23 on the CMS1500
form.
Occasionally, the representative says that because the provider is not in the network, authorization is
required and the claim is denied. When that occurs, treat it as a case of 242: Services not supplied by
network/primary care providers rather than an Auth denial.

Pre-authorization, also known as prior authorization, is the process of getting permission before starting
a treatment.

Retro Authorization: This is the process of applying for permission after the procedure has been
completed.

Situation of On Call:

Claim rejected due to lack of authorization

Could you please let me know when the application was denied?

Check in system if Auth# is Available

↙ ↘

Yes No

↓ ↓

I have the Auth#. Would you kindly check the location of the service that was billed on and use
this Auth# to reprocess the claim? is 23 (Emergency) in the claim or not

↓ ↗ ↙ ↘

Rep Agrees? ↗ Yes No

↙ ↓ ↗ ↓ ↓

Yes No ↗ ↓ Is your Auth# currently on file?

Alternatively Would you kindly ask whether there is a hospital claim?

Which way is it? When an authorization number is present, does the claim need to be reprocessed
and billed on the same DOS where the around time was sent an invalid authorization number?

for handling? updated emergency service (The above highlighted question

↓ claim & does not require is only applicable for

May I have the ↓ Auth#? billing claims not related to hospitals

claim# and call reference number? What is ↓ ↗ ↙

↘

the time Rep Is in Agreement? ↗ Yes No

limit to send ↙ ↘ ↗ ↓ ↓

a corrected Yes No ↓ ↓
 claim? ↓ Would you kindly Is it feasible to
What's the turnaround time? Use that authorization number to get Retro

Could you please give it to me again for processing? submit the claim back for the
authorization number?

claim#& call reference number?

Please grant me permission to access the Not at all

claim#& call ref#?

What's the What is the

procedure to obtain Fax# or mailing

retro Auth#? address to send

↓ an appeal?

Would you please give me the claim# and

call? What is the ref# of this item? the time limit?

May I have the

claim# & call

ref#?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

Set the follow-up for the TAT that the representative provides if the Auth# is present in the system and
the representative consents to reprocess the claim.

Update the Auth# accurately and submit the corrected claim by updating the correct billing code "7"
along with the claim number if the Auth# is available in the system and the representative requests to
send a corrected claim instead of reprocessing the original one.

Set the follow-up for the representative's TAT if the Auth# is not present in the system, the service is an
emergency, and the representative consents to reprocess the claim.

Set the follow-up for the representative's TAT if the Auth# is not available in the system, the service is
not an emergency, and the representative locates the Auth# in his or her system or on the hospital claim
and agrees to reprocess the claim.
Follow the rep's instructions if the Auth# is not available in the system, the service is not an emergency,
and the rep cannot locate the Auth# in the hospital claim or in his or her own system but claims that
retroauthorization can be obtained.

Obtaining retro authorization requires completing the form and mailing the required paperwork. You
can fill out the form, attach the necessary documents, and mail the documents to the insurance
company if you have access to them.

You can inquire with the client if the documents are not readily available.

The claim must be written off if the Auth# is not available in the system, the service is not an emergency,
the representative cannot locate the Auth# on the hospital claim or in his or her system, and he or she
states that it is not possible to obtain retro authorization. However, if nothing can be done, clients
occasionally wish to send an appeal. Thus, follow the directions provided by your client.

For the payers listed on the Evicore website, the Auth# is also available. The Auth# authorized for the
particular CPT code during the specified time frame is provided on this page.

Few insurance policies suggest obtaining an Auth# by contacting Evicore insurance. Therefore, if you
have access to the website, you can check immediately to see if the Auth# has been approved for the
CPT; if not, you can call Evicore Insurance to find out the specifics.

To access Quiz, click this link.

199: Revenue code and Procedure code do

not match
Call Scenerio:

Claim rejected due to discrepancy between revenue codeand procedure code

MayI have the date of denial?

Check patient payment history if the same

CPT code paid with the same revenue code

↙ ↘

Yes No

↓ ↓

Would you kindly process the claim again for payment? Could you advise which revenue code,
for the same CPT and revenue code, should have been received? or CPT code? (Reps rarely have
this information, but occasionally they do.)
 How long does it take to reprocess? suggest accurate information) ↑

Could you please provide the claim number and call reference number? Is
there a deadline for sending a corrected claim?

What is the Fax# or Mailing

address to send an appeal?

What is the duration within which an appeal can

be sent?

Could you please provide the claim number and

call reference number?

Important Note:

A coding team should be tasked with reviewing this denial; in the notes provided by the representative,
please include all relevant information and suggestions. This facilitates the coding team's provision of
the accurate CPT or revenue code.

If the deadline for submitting the corrected claim is not missed, submit the corrected claim to insurance
by updating the correct code as soon as you receive a response with the correct revenue code or CPT
code.

Work in accordance with the client's request, which occasionally requires us to submit the updated
claim even after the deadline has passed.

Send an appeal to insurance if the coding team determines that the revenue code and CPT code are
correctly coded.

Calculate the time limit from the denial date before filing an appeal. If the time limit is not exceeded, file
the appeal; if it is, write off the claim.

Work in accordance with the client's request, which occasionally requires us to send the appeal after the
deadline has passed.

226: Information requested from the

Billing/Rendering Provider was not
provided or not provided timely or was
insufficient/incomplete
Situation of On Call:
 Claim rejected due to Medical Records Requested

Could you please let me know when the application was rejected?

Which mailing address or fax number should I use to send the MR?

What is the duration of the record-sending deadline?

Could you please provide the claim number and call reference number?

Important Note:

Determine the time limit starting from the denial date. If it hasn't passed, send the MR; if it has, write
off the claim.

Work in accordance with the client's request to send MR even if the deadline has passed.

Always verify the comment code provided along with the denial reason; occasionally, it gives the precise
reason for denial, which may vary. In order to work out the precise denial, use the AR scenario tool.

227: Information requested from the

patient/insured/responsible party was not
provided or was insufficient/incomplete
Denial Occurrences: When a patient is asked for any information, including COB or other information, a
denial takes place.

A letter is sent to the patient requesting information, and it could take some time to hear back from
them with an update. Therefore, before sending the letter to the patient, we should give ourselves at
least 15 to 30 days.

Coordination of Benefits, or COB, is an acronym that aids in classifying insurance as primary, secondary,
or tertiary.

Situation of On Call:

Claim rejected or pending while more patient information is sought

When was this claim received by you?

Could you please let me know when the application was denied?

(In the event that the claim is rejected)

What details have you asked the patient for?

↙ ↘
The patient must update their COB data. Other Reasons

↓ ↓

Have you written the patient a letter? Have you written the patient a letter?

↙ ↘ ↙ ↘

Yes No Yes No

↓ ↓ ↓ ↓

When did you When was the patient last seen? When did you send the letter? Could
you please let me know? has the COB updated the letter that was sent? claim# and Call
ref#? ↓

Have you been given anything? Have you heard back from the patient? Could you
please let me know if you have? claim# and call reference#? patient?

Yes No Yes No

↓ ↘ ↓ ↘

Could you When did the sufferer Would you please reprocess the most recent
update, claim#, and call reference number for the claim? COB details? the assertion?

↓ ↓ ↓

What's the TAT? Could I please have the How long does it take to reprocess? claim#
and call reference# for further processing?

↓ ↓

Could I please have the claim number and the call number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

Set the follow-up for the TAT that the representative provides if the patient is asked for COB/Other
information, the letter has already been sent, the patient has responded, and the representative agrees
to reprocess the claim.

The patient may be released from the claim if COB or other information is requested from them, the
letter has been sent, and they have not responded.

Do not charge the patient for the claim if the 30-day period that has passed since the letter was sent to
them has not passed. Give the patient a minimum of 30 days to update the information. After that time
has passed, bill the patient for the claim. But always do as instructed by your client.
The patient may be released from the claim if the COB or other information is requested from them and
the letter is not sent.

If the patient's payment history indicates that any other insurance was used to pay for the claim on the
nearby DOS as primary insurance, you can investigate their eligibility and bill the claim to that insurance
if the policy is active on DOS as primary. This is something you can do if the claim is denied or pending
for COB updates.

234: This procedure is not paid separately

Situation of On Call:

Claim rejected because procedure code is not paid separately

Could you please let me know when the application was denied?

Which is the main CPT code?

The representative offers the primary CPT code.

Yes No

↙ * Check claim form both CPTs What is the deadline for sending a corrected claim that
has been billed on the same claim form or not?

↙ ↘ ↓

Yes No Which is the mailing address or fax number to

send an appeal to?

Would you kindly reprocess? What is the deadline for sending a corrected claim when CPT has
already received the original claim? What is the amount of the time limit charged with primary
CPT? ↑ To send an appeal? What is the mailing address or fax number for ↑

What is the turnaround time (TAT) for mailing an appeal? Could you please provide the call
reference number and claim number?

Reprocessing? ↓ What is the duration?

Could you tell me the maximum amount that I can send in an appeal?

claim# and call reference #? ↓

Could you please provide the claim number and call reference number?

Important Note:

Assign the claim to the coding team so they can determine the primary CPT code if the representative
fails to provide the correct primary CPT code.
Create that CPT and resubmit both codes if the coding team replies with the correct primary CPT code
and the code is not in the system.

Details about primary procedures can also be found if you have access to tools like findacode and
encoder. Call the insurance company to reprocess the claim once you determine that CPT can be billed
separately. Send an appeal if the representative declines to reprocess the claim.

Resources to Determine Bundle CPT Codes

236: In accordance
with the National Correct Coding Initiative
and workers compensation state
regulations/fee schedule requirements, this
procedure or procedure/modifier
combination is incompatible with another
procedure/modifier combination provided
on the same day.
Situation of On Call:

Claim rejected because the combination of procedures is incompatible with

another procedure.

May I get the denial date?

To which CPT is it bundled with?

What is the deadline for sending a corrected claim?

Could you please provide the appeal mailing address or fax number?

Important Note:

The coding team should be notified of this denial in order to determine whether or not the claim can be
resubmitted by updating the modifier.
You can also verify the NCCI edit between procedures if you have access to the encoder, findacode, etc.
tools. You can use these tools to determine whether or not there is an NCCI edit between CPTs that are
billed on the same DOS. If so, whether or not it can be overridden by applying the proper modifier.
Additionally, it offers the best modifier to override the CPT. CPT should be written off if it cannot be
overridden.

Update it and send the updated claim to insurance if the coding team's response includes the correct
modifier, or if you find the correct modifier using any tools. Send a new claim to Medicare since they will
not accept the amended one.

Call the insurance and request that the claim be reprocessed if the coding team's response indicates
that the coding is correct or if you discover that there isn't an NCCI edit using any tools. Send an appeal
to insurance if they reject.

Resources to Determine Bundle CPT Codes

242: Services not provided by

network/primary care providers (Provider is
Out of Network)
Denial Occurrence:

This kind of denial happens when the service provider is not under contract with the insurance
company.

If out-of-network benefits are covered by the patient's policy in this case, the claim may be paid.

The patient may be billed for out-of-network benefits if their policy does not cover them.

The out-of-network benefit is not covered by the HMO or EPO plan.

The PPO or POS plan provides coverage for out-of-network benefits.

Situation of On Call:

Claim rejected for non-covered services; patient plan states that provider is
not in network;

Could you please let me know when the application was denied?

Does the patient plan cover benefits that are not covered by the network?

What kind of plan does the patient have? (POS, EPO, PPO, and HMO)

↙ ↙ ↘ ↘
 ↙ ↙ ↘ ↘

HMO PPO EPO POS

↙ ↓ ↓ ↘

Would you kindly allow me to have the Could you please provide the claim# and call
reference number? reprocess the claim with the claim number and call reference? Reprocess
the claim since the patient plan does not cover out-of-network benefits in terms of reimbursement for
medical expenses or other benefits? network advantage?

↓ ↓

What's the TAT? How long is the time between

assignments (TAT) for reprocessing? for reprocessing?

↓ ↓

Could I please have the claim# and call reference number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

If the representative agrees to reprocess the claim and it is rejected as non-covered charges under the
patient plan because the provider is out of network and the patient has a PPO or POS plan, then
schedule the follow-up for the representative's recommended time frame.

Bill the claim to the secondary or consecutive payer, if available, or release it to the patient if the claim is
denied as non-covered charges under the patient plan because the provider is out of network and the
patient has an HMO or EPO plan.

The patient's eligibility for the secondary or consecutive payer must be confirmed before billing the
claim to that payer.

If access to the payer website is available, use it to confirm the eligibility of secondary or consecutive
payers; if not, contact the insurance provider.

Release the claim to the patient if there isn't another payer on DOS that is active or accessible.

To access Quiz, click this link.

288: Referral absent

Denial Occurrence:

When the referral is absent, this denial takes place.

The referral number is located on Locator #63 on the UB04 form or Box # 23 on the CMS1500 form.
When a PCP (Primary Care Physician) or Referring Provider refers a patient to a specialist, that referral is
made on their behalf.

For instance, during a routine check-up, if a patient's doctor discovers symptoms of a skin condition, the
doctor may recommend that the patient see a skin specialist. In that scenario, the physician refers the
patient to a skin specialist and is regarded as a PCP or referral provider.

It is required under the HMO or POS plan to see the PCP. Thus, a referral is necessary.

The PCP visit is not required under the PPO or EPO plans. Thus, a referral is not necessary.

Situation of On Call:

Claim denied as referral is absent or missing

May I get the denial date?

What kind of plan does the patient have? (HMO, PPO, EPO, POS)

↙ ↙ ↘ ↘

↙ ↙ ↘ ↘

HMO POS PPO EPO

↘ ↙ ↘ ↙

↘ ↙ ↘ ↙

Please check the system to see if there is anything you need to do. If so, could you send
the claim back for reprocessing since the referral number is available? Patient plan is
not necessary

Yes No referral#?

↙ ↓ ↓

Can you check if you have the referral# on file? I have it. Could you please reprocess?
What is the turnaround? Does the hospital have a claim time policy?

the assertion made with it? billed on same DOS where ↓

↓ referral# present? Could you please give me the claim

number?

What is the turnaround time (the question that is highlighted above) and call reference number?

moment? is only relevant to ↑ non-hospital billing claims

Could you please provide me with the claim#↙↞↞ ↞ ↞ & call ref#? Yes
No

↓ ↓

Would you kindly make use of What is the Fax number or the same referral
number, and could you please send the mailing address to claim back for sending an appeal?

reworking? ↓

↓ What is the duration?

What is the limit for the turn around process?

moment? ↓

↓ Could you please give me the claim number?

Could you please provide the claim# and call reference number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

Set the follow-up for the representative's TAT if the patient plan is an HMO or POS, the referral is in the
system, and the representative consents to reprocess the claim.

Set up the follow-up for the representative's TAT if the patient plan is an HMO or POS and the referral is
not in the system, but the representative locates it in his or her system or on the hospital claim and
agrees to reprocess the claim.

You may file an appeal or write off the claim if the patient plan is an HMO or POS, the referral is not in
the system, and the representative cannot locate the referral on the hospital claim or in his or her own
system. Please follow the directions provided by your client.

If the representative agrees to reprocess the claim and the patient plan is PPO or EPO, schedule the
follow-up for the TAT that the representative provides.

To access Quiz, click this link.

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
Call Scenario:

Claim rejected because primary payer is another

Could you please let me know when the application was denied?

Would you kindly inform me which insurance is the primary insurance?

Does the representative have the information?

↙ ↘

Yes No

↙ ↘

Which dates are the effective and term dates of the policy? Could you please provide
the claim number and term? & dial the reference number?

Representative is in possession of the information. The representative lacks

information.

Was DOS policy in effect? What is the policy id, payer id

↙ ↘ & mailing address of primary

Yes No insurance?

↓ ↓ ↓

What is the situation? Would you kindly I would like the policy ID, payer ID, claim number, and
call reference number to be reprocessed.

& mailing address, as there isn't any active primary insurance? What's the turnaround
time?

Could you please provide me with the claim# and call reference? Could you please provide the
claim number and call reference number?

Important Information:

In the event that the representative lacks primary insurance information, check in the system to see if
the patient has any other insurance that is available or if the patient's payment history indicates that
another insurance is primary. If so, determine whether the patient is eligible for that insurance,
resubmit the claim to the payer if the policy is active as primary, or release the claim to the patient if no
other insurance information is available.

If access is granted, you can also check the payer web portal to obtain primary insurance details.
There's a chance that the primary insurance is inactive when the representative gives you the details of
it and you have access to the primary insurance web portal. Therefore, you should always check your
eligibility via the website.

You can update the primary insurance as primary, make the current insurance secondary, and
resubmit the claim to the primary insurance once the representative has given you all the information
about the primary insurance.

Click Here to follow the primary EOB scenario if the claim has already been paid by the primary
insurance.

B7: This provider was not

certified/eligible to be paid for this
procedure/service on this date of service
Situation of On Call:

Refusal of claim as On the day of service, this provider was not certified or
eligible to be paid for this procedure/service.

Could you please let me know when the application was denied?

What precisely is the problem?

↙ ↓ ↘

The supplier of renderings The source of the referral The procedure code is inconsistent; it is
not authorized to perform; it is not authorized to refer; it is not authorized to perform with the provider
type/specialty; the service billed; the service billed; the taxonomy code is invalid;

Go Here Go Here Go Here

Important Information

To follow along with a particular scenario, click the link.

B9: Patient enrolled in a Hospice

Hospice: A patient is eligible for hospice care if they have a terminal illness for which there is no cure
and their life expectancy is less than six months.
When a patient receives a diagnosis of a treatable illness but refuses to take life-threatening medication,
the patient also qualifies for hospice care if their remaining time is less than six months.

The patient no longer receives treatment aimed at curing or managing the illness once hospice care is
selected. Only pain relief will be provided to the patient.

The beneficiary forfeits all claims to Medicare Part B payments for hospice-related services when they
choose hospice coverage.

Services related to hospice that are rendered by the "attending physician" under contract or employed
by hospice should be reported to the hospice contractor.

Medicare part B claims pertaining to hospice-related services rendered by a "attending physician" who is
not employed by the designated hospice or does not receive payment from it for such services should
be filed under the GV modifier.

A GW modifier must be applied to Medicare Part B claims for any services rendered to a patient that are
not associated with a hospice condition.

Denial Occurrence: This kind of denial happens when a patient is enrolled in hospice care and Medicare
or Hospice are not billed for the claim.

This denial also happens when a claim is billed to Medicare Part B without a GV or GW modifier and the
patient is enrolled in hospice care.

The GV or GW modifier must be added when a patient is enrolled in hospice care and the claim is billed
to Medicare Part B.

Situation of On Call:

Claim denied as patient enrolled in Hospice

May I get the denial date?

Could you please let me know the start and end dates of the hospice enrollment?

Verify whether the DOS falls within the hospice enrollment period.

No Yes

↓ ↓

Could you please send the hospice information back for reprocessing since the patient was
not enrolled in hospice on dos? Examples of this information include the hospice name, NPI, and mailing
address. & ID policy?

↓ ↓
 Could you please provide me with the Claim# for reprocessing and let me know what the
turnaround time is? & Call reference number?

Could you please provide the Claim#, Call ref#, and Reference number?

Important Reminders & Steps:

Kindly follow your process update by taking appropriate action. The actions listed below might differ
from your process update.

You can schedule the follow-up for the TAT that the representative provides if the DOS does not fall
between the hospice enrollment period and the rep sending the claim back for reprocessing.

You can update hospice as primary insurance and submit the claim if the DOS occurs between the
hospice enrollment period and the time the representative gives you the hospice information.

Sometimes, the insurance rep does not provide hospice information and gives NPI numbers. In such a
case, get the hospice's name and mailing address via the NPPES website. An SSN may also be utilized as
a policy ID. You can also find this NPI number under the hospice tab on the Medicare portal.

You can release the claim to the patient if the DOS occurs during the hospice enrollment period, the
representative does not provide any information about hospice, and there are no Medicare details
available. Nonetheless, follow your client's instructions.

Medicare or Hospice must be billed if the patient's insurance is denied by a commercial provider and
they are enrolled in hospice care on DOS. Never send it in again for commercial insurance.

M119:
Missing/incomplete/invalid/deactivated/with
drawn National Drug Code (NDC)
Situation of On Call:

Refusal of claim due to missing or incorrect NDC code

Could you please let me know when the application was denied?

Verified if the NDC number is available on the claim form.

Verified whether the NDC number is present in the system?

↙ ↘

Yes No

↓ ↓
 We've already billed the claim using the NDC number. ↑

Would you kindly verify that it is correct? // ↑

I possess the NDC number; could you kindly verify whether or not it is accurate?
↓

↙ ↘ ↓

Yes No ↓

↓ ↘ ↓

Would you kindly process the claim again? Would you kindly supply the accurate NDC number?

↓ ↙ ↘

Rep agrees Rep gives accurate The representative declines to supply

The NDC number is the accurate number.

Yes No ↓ ↓

↙ ↘ What is the duration? Do a Google search to learn more.

What's the TAT? How do I submit a corrected claim? suitable NDC code and for further
processing? the reason? ↓ verify with rep,

↘ ↙ Would you please give me the Is that right or wrong?

Could you please provide the claim number and call reference number? claim# and call reference
number? ↙ ↘

If it is correct If it is not correct

↘ ↙

What is the period of time within which I

can submit a corrected claim?

Could I please have the claim# and call

reference number?

Important Note: Only the Drug CPT code requires the NDC code. A letter is always used to begin a drug
code. J0256, J2425, J7649 are a few examples.

The NDC code in CMS1500 form can be found in the line item fields 24A–24G'sshadedarea, as seen in
the image below.
 The NDC code can be found in field 43 of the UB04 form, as seen in the image below.

Both of the images demonstrate how an NDC code should be billed on a claim form with the NDC
Qualifier, NDC code, NDC unit of measure, and number of NDC units included in the format.

Update the NDC code in your software or on the clearing house if the representative supplied the
accurate one, then resubmit the updated claim.

Assign it to the client for assistance if you are unable to update the NDC number on the clearinghouse or
software. Proceed as necessary if your client has already given you the instructions for this scenario.

Even when you call or use Google to find the correct NDC code, things can still go wrong. In order to
make updates to the clearing house's software, "NDC units of measure" and "NDC units" are required.
Therefore, it would be best to ask the client or seek assistance from the appropriate department if you
do not have all of this information.

If you are unable to locate the correct NDC code, either follow the client's instructions or assign the
problem to them for assistance.

To learn more about the NDC code, go here.