CO16 denial code description and corrective action

• This denial mostly occurs due to an error in the claim submitted to the insurance or missing some element of claim or because additional information is required by the insurance to process the claim.

• To identify the exact missing information, we need to review the remark codes provided in the EOB/ERA, as they specify what is incomplete, invalid, or required for the claim.

• For example, if the rendering provider’s NPI is missed during billing, the claim will be denied with CO16, indicating that information is missing. Along with it, remark code N290 will appear, specifying that the missing information is the rendering provider’s primary identifier.

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 first and 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 ask the representative to provide the exact reason for the claim denial. If the denial reason appears to be incorrect, request the representative to reprocess the claim. Make sure to note the claim number, the representative’s name, and the call reference number, and then follow up on the claim after the TAT provided.

• Also, on the ERA and EOB, there are remark codes included that specify the exact reason for the denial, helping to identify what information is missing or what correction is required.

• Consult coding specialists if the denial reason is related to coding. If not, review the supporting documents to confirm and validate the denial reason.

• If the coding is correct, or if after verification the denial reason appears to be incorrect, then we proceed with submitting an appeal.

• For submitting an appeal, we 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 appeal even after the timely filing limit has passed, so we should proceed according to their instructions.

• If we determine that the denial is accurate, then we submit a corrected claim with the required modifications. If the insurance requires additional documents, we provide them through fax, mail, portal, or any other available method. If the document is not available, then we contact the client to provide the required document so we can proceed further.

• Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.

Description