B16 denial code description and corrective action

New patient criteria not met.

If a patient visited the doctor within the last 3 years, then they would be considered an established patient. If more than 3 years have passed since the last visit, then they would be considered a new patient.
There are procedure codes that specifically differ based on whether the patient is new or established. If the patient is established and we bill a code for a new patient, then we get this denial.

First, we need to verify the status of the claim. This can be done by checking the status through the insurance web portal or by calling the payer.
The most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake.
Call the insurance company and confirm the last visit, or check our system to verify the patient’s last visit. If there is no other visit or if the last visit was more than 3 years ago, then ask the representative to reprocess the claim as it is now considered a new patient. Be sure to note the claim number, rep name, and call reference number, and then follow up on the claim after the provided TAT.
If it is found that the patient is not new and already had a visit within the last three years, then contact the coding team to suggest an alternate procedure code.
After receiving the coding response, submit a corrected claim with the required modifications (correct procedure).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an corrected claim, must calculate the timely filing limit starting from the processed date. If the limit has been exceeded, the claim will be denied again for exceeding the filing deadline. In such cases, we should consult with the provider. Some clients may still want us to submit the corrected claim even after the timely filing limit has passed, so we should proceed according to their instructions.