CO163 denial code description and corrective action

• This denial occurs when the documents referenced on the claim have not been received by the payer.

• In most cases, a remark code will be provided that clearly specifies which document is required but has not yet been received.

• For example, if the insurance requires primary payment information or a primary EOB but has not yet received it, this denial may be issued.

• There are multiple documents that the insurance may require but not receive, which could cause this denial. Here, I will explain only the EOB missing scenario.

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 and confirm with the representative what exactly is required.

  Let the representative confirm that the primary payment information is required.

  Check Box #29 on the CMS-1500 form and Box #54 on the UB-04 form to verify whether the primary insurance payment information is present.

  If the information is present, ask 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 TAT.

  If there is no information but the primary has paid the claim, then submit the EOB through mail or fax.

• If there is no other primary insurance information is available in our system, ask the representative to provide the primary insurance details.

• If the representative provides primary insurance information, verify eligibility and then bill the claim to the primary insurance.

  If the representative does not have the information, check the patient’s history, documents, and portal to obtain primary insurance details. If found, verify eligibility and then bill the claim to the primary insurance.

• Before submitting the document, verify the timely filing limit (TFL) for submission. If it has been exceeded, proceed according to practice SOPs or client suggestions.

Description