CO183 denial code description and corrective action

• This type of denial most often occurs when the referring provider’s specialty is different.

• It also may occur when the referring provider is not enrolled with the insurance or group.

• Sometimes it also may occur when the referring provider information is missing in the claim.

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, if claims in the member’s history with the same coding have been paid with the same information of providers, and ask the representative to reprocess the claim. Be sure to note the claim number, rep name and call reference number, and then follow up on the claim after the provided TAT.

• Confirm with the representative what the actual cause of this denial is.

• If the referring provider’s specialty is different, consult the client to obtain the exact details of the referring provider and proceed according to the action suggested by the client.

• If the referring provider is not enrolled with the group or insurance, then ask the client to complete the enrollment process.

  To check enrollment in Medicare, visit the PECOS website and follow the prompts.

• If the denial is due to missing referring provider information, first check the information on our end. If it is present, ask the representative to double-check. If the information is also available on the insurance end, request the representative to reprocess the claim, note the necessary details, and follow up on the claim after the given TAT.

  If the information is present in our system but the insurance did not receive it in the claim, then it is considered a system error. In this case, we resubmit the claim. If the information still does not update on the new claim, we proceed with submission through mail or fax.

• If the referring provider information is not available in the claim in our system as well, then we resubmit a corrected claim with the required information.

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

Description