CO119 denial code description and corrective action

• Sometimes, a policy places limits on certain services or procedures, allowing payment only up to a specified dollar amount or number of visits per year or lifetime maximum. Once the service reaches that limit, the insurance denies the claim.

• For example, if a service has a payment limit of $2000 and the patient has already visited the provider eight times for the same service with the insurance paid the full $2000, then any further claims for this service will be denied with this denial code.

• For example, if a service has a limitation of a maximum of 5 visits under the member’s plan, and the patient has already visited the provider 5 times for the same service and insurance processed those visits, then any additional claims for this service will be denied with this denial code.

Actions

• 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 to verify the service limitation, and if it is confirmed that the limit has not yet been exceeded, request the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and follow up on the claim after the provided turnaround time (TAT).

• If the representative states that the limit has been exceeded and the limitation is based on a dollar amount, confirm with the representative the dates of service (DOS) on which the insurance made payments and verify the total paid amount. If the limitation is based on the number of visits, obtain the details of the processed DOSs.

• If it is confirmed that the limit has truly been exceeded, bill the claim to the secondary insurance after verifying eligibility.

• If there is no active secondary or consecutive payer, release the claim to the patient.

Description