CO55 denial code description and corrective action

• This denial occurs when the insurance considers the services performed to be experimental or investigational.

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.

• Call the insurance company, if claims in the member’s history with the same coding have been paid, 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.

• In most cases, reimbursement for this procedure is very difficult after this denial. Therefore, consult the coding team to determine if there is an alternate procedure code that can be used for this service.

• If they provide an alternate procedure code, submit a corrective claim with the updated procedure.

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

• If the coding team confirms that there is no alternate procedure, proceed with submitting an appeal along with supporting documents and medical notes.

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

• Make sure to share this procedure with the client, as sometimes they have updates from the insurance regarding certain services, and they may allow the procedure to be written off if this denial is received.

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