1
Deductible
Deductible is contracted (between member and insurance) $ amount member have to pay before insurance start to pay. It always come with PR category.
Example
A patient has a contracted deductible of $1,000. When the patient visits the doctor, the insurance company reviews the claim and allows $800 for the services performed. Since the deductible has not yet been met, the entire $800 is applied toward the deductible, meaning the insurance does not pay anything for this visit. The patient is responsible for paying the full $800. After this payment, the patient still has $200 remaining to meet the deductible
After a few days, the patient visits the doctor again, and this time the insurance company allows $400 for the services. Since $800 has already been applied to the deductible, the remaining deductible balance is $200. Therefore, $200 of the allowed amount is applied toward the deductible, and the patient is responsible for paying that portion. The remaining $200 is covered by the insurance company, assuming there is no coinsurance. At this point, the patient’s $1,000 deductible is fully met, and future covered services will be paid according to the plan’s benefits.
In simple terms, a deductible is the amount a patient must pay before the insurance company begins to cover any costs.
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, as we need the Explanation of Benefits (EOB) of the claim.
If we call the payer and find that the claim has been processed entirely as deductible, we must collect key details, including the allowed amount, deductible amount, claim number, processed date, the name of the representative, and the call reference number. In addition, we must request a copy of the Explanation of Benefits (EOB) through the available method, whether by mail, fax, or email.
If a claim is processed incorrectly as deductible, we must ensure that it is sent back for reprocessing and then follow up on the claim after the turnaround time (TAT) provided by the representative.
After receiving the EOB, we will either post it ourselves or forward it to the person responsible for posting payments.
Before billing the deductible amount to the patient, we must confirm whether there is any active secondary insurance. If a secondary policy exists, we verify the eligibility and then send the claim to the secondary payer.
Sometimes, especially in the case of Medicare, the insurance will automatically crossover the claim to the secondary payer. In this scenario, we wait up to 30 days, and if no response is received from the secondary insurance, we then contact them and take the necessary action.
If there is no secondary insurance, then we release the claim to the patient.
2
Coinsurance
Patient’s share of the costs for covered healthcare services, calculated as a percentage of the allowed amount is coinsurance. It always come with PR category.
Example
Let us consider a 20% coinsurance. This means the insurance company will cover 80% of the allowed amount, while the remaining 20% will be the patient’s responsibility.
Imagine a patient visits the doctor, and the insurance allows $500 for the services performed. Since the patient has already met their deductible and there is no copayment in the contract, only the coinsurance applies. With a 20% coinsurance, the patient is responsible for $100 (20% of $500), while the insurance covers the remaining $400 (80% of $500).
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, as we need the Explanation of Benefits (EOB) of the claim.
If we call the payer and find that the claim has been paid along with some coins, we must collect key details, including the allowed amount, paid amount, check or EFT number, payment date, Coinsurance amount, claim number, processed date, the name of the representative, and the call reference number. In addition, we must request a copy of the Explanation of Benefits (EOB) through the available method, whether by mail, fax, or email.
After receiving the EOB, we will either post it ourselves or forward it to the person responsible for posting payments.
Before billing the coinsurance amount to the patient, we must confirm whether there is any active secondary insurance. If a secondary policy exists, we verify the eligibility and then send the claim to the secondary payer.
Sometimes, especially in the case of Medicare, the insurance will automatically crossover the claim to the secondary payer. In this scenario, we wait up to 30 days, and if no response is received from the secondary insurance, we then contact them and take the necessary action.
If there is no secondary insurance, then we release the claim to the patient.
3
Copayment
It is a set Price (Portion of bill) patients pays when they visit doctor. This amount is in contract with insurance and depends of the type of plan patient hold. It always come with PR category.
Example
Let us consider a $30 copayment. This means that the first $30 of every claim allowed amount would be the responsibility of the patient and would be processed as copayment.
Imagine a patient visits the doctor, and the insurance allows $500 for the services performed. Since the patient has already met their deductible and there is no coinsurance in the contract, only the copayment applies. With a $30 copayment, the patient is responsible for $30, while the insurance covers the remaining $470.
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, as we need the Explanation of Benefits (EOB) of the claim.
If we call the payer and find that the claim has been paid along with some copay, we must collect key details, including the allowed amount, paid amount, check or EFT number, payment date, Copayment amount, claim number, processed date, the name of the representative, and the call reference number. In addition, we must request a copy of the Explanation of Benefits (EOB) through the available method, whether by mail, fax, or email.
After receiving the EOB, we will either post it ourselves or forward it to the person responsible for posting payments.
Before billing the copayment amount to the patient, we must confirm whether there is any active secondary insurance. If a secondary policy exists, we verify the eligibility and then send the claim to the secondary payer.
Sometimes, the insurance automatically crossover the claim to the secondary payer. In this scenario, we wait up to 30 days, and if no response is received from the secondary insurance, we then contact them and take the necessary action.
If there is no secondary insurance, then we release the claim to the patient.
CO4 denial code description and corrective action
Procedure code is inconsistent with the modifier used or required modifier is missing.
Description
A modifier is a two-digit (Numeric or alphanumeric) code added to a CPT or HCPCS procedure code in medical billing. It provides additional information about the service or procedure performed without changing its basic definition.
For the use of modifiers, we must keep in mind their proper combination with the CPT code. If a modifier is not appropriate or does not align with the procedure code, the claim may be denied with this denial code.
For example, if we bill a procedure code that relates to the right side of the body but use the modifier LT (which indicates the left side), the claim will be denied with this code as procedure code is inconsistent with the modifier used.
Sometimes a modifier is necessary to provide complete and accurate information, but if we fail to include it, the claim will also be denied with this denial code as the required modifier is missing.
For example, in physical therapy services, the GP modifier is often required. If this modifier is omitted, the claim will be denied with this denial code indicating that the modifier was required but missing.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 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 and call reference number, and then follow up on the claim after the provided TAT.
Consult coding specialists or use reliable websites to determine whether a modifier is required and if the modifier used is accurate or not.
If the coding is correct, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (Correct modifier).
Sometimes we bill two service lines with the same procedure code using LT and RT modifiers. In such cases, the insurance may pay for one line and deny the other with this denial code. To resolve this, we submit a corrected claim with a single service line, double the charge amount, and append the bilateral modifier.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO5 denial code description and corrective action
Procedure code is inconsistent with Place of service.
Description
This denial occurs when the procedure code billed is not compatible with the place of service reported on the claim.
For example, if we bill a procedure code that is meant only for outpatient services, such as 99213, but use POS 21 (which is specifically for inpatient services), the claim will be denied with CO5 because the CPT code and the place of service do not align with each other.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, if claims in the member’s history with the same coding (CPT, POS combination) 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.
If rep provide correct POS then we'll submit corrective claim.
Consult coding specialists or use reliable websites to determine whether the procedure and place of service combination used is accurate or not.
If the coding team confirms that the combination is correct, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct POS).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO6 denial code description and corrective action
Procedure code is inconsistent with Patient's age.
Description
This denial occurs when the procedure code billed is not compatible with age of the patient.
There are certain procedure codes that are age-specific, and if we bill one of these codes for a patient whose age does not match the requirements of the code, the claim will be denied with this denial code.
For example, the preventive care code 99397 is used for patients aged 65 years or older. If this code is billed for a patient younger than 65, the claim will be denied with CO6, indicating that the patient’s age does not match the requirements of the procedure code.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists or use reliable websites to determine whether the procedure is appropriate with patient's age or not.
If the coding team confirms that the procedure is correct, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct procedure).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO7 denial code description and corrective action
Procedure code is inconsistent with Patient's gender.
Description
This denial occurs when the procedure code billed is not compatible with patient's gender.
There are certain procedure codes that are gender-specific, and if we bill one of these codes for a patient whose gender does not match the requirements of the code, the claim will be denied with this denial code.
For example, let us consider a code that is purely for females and could never be use for male, and our patient is a male and we billed this procedure then we receive the denial code CO7, that procedure is inappropriate with gender.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists or use reliable websites to determine whether the procedure is appropriate with patient's gender or not.
If the coding team confirms that the procedure is correct, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct procedure).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO8 denial code description and corrective action
Procedure code is inconsistent with Provider's type/specialty/taxonomy.
Description
This denial occurs when the procedure code billed is not compatible with provider's specialty, taxonomy..
Each provider has a specialty in a specific field of medicine, such as cardiology, podiatry, physical therapy, or psychology etc. If a procedure code is billed that does not fall within the provider’s specialty, the claim will be denied with this denial code.
For example, if the provider is a podiatrist and we bill code 90832 (psychotherapy), the claim will be denied because these services do not fall under the provider’s specialty.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 or history of any other patient with the same coding and billed under same provider, have been paid, then we 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.
We also check all provider information used in the claim is accurate or not. If we found something wrong then we submit corrective claim with correct provider's information.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
Consult coding specialists or use reliable websites to determine whether the procedure is appropriate with provider's specialty or not..
If the coding team confirms that the procedure can be performed by respective provider, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we contact the client to inform them that the mentioned services cannot be performed under their specialty. After that, we proceed according to the provider’s instructions.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO9 denial code description and corrective action
Diagnosis code is inconsistent with Patient's age.
Description
This denial occurs when the diagnosis code is not compatible with age of the patient.
There are certain diagnosis codes that are age-specific, and if we bill one of these codes for a patient whose age does not match the requirements of the code, the claim will be denied with this denial code.
For example, the Dx code Z00.110 and Z00.11 is used for newborns till 8 days old and 8 days to 28 days old respectively. If these codes billed for an adult, the claim will be denied with CO9, indicating that the patient’s age does not match the requirements of the diagnosis code.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists or use reliable websites to determine whether the diagnosis code is appropriate with patient's age or not.
If the coding team confirms that the diagnosis is appropriate with patient's age, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct diagnosis).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO10 denial code description and corrective action
Diagnosis code is inconsistent with Patient's gender.
Description
This denial occurs when the diagnosis code billed is not compatible with patient's gender.
There are certain diagnosis codes that are gender-specific, and if we bill one of these codes for a patient whose gender does not match the requirements of the code, the claim will be denied with this denial code.
For example, let us consider a diagnosis code that is purely for females and could never be use for male, and our patient is a male and we billed this procedure then we receive the denial code CO10, that diagnosis is inappropriate with gender.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists or use reliable websites to determine whether the diagnosis is appropriate with patient's gender or not.
If the coding team confirms that the diagnosis is appropriate, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct diagnosis).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO11 denial code description and corrective action
Diagnosis code is inconsistent with the procedure.
Description
This denial occurs when the diagnosis code billed is not compatible with the procedure.
Diagnosis codes represent the illness or condition, while procedure codes represent the treatment or service provided. If the diagnosis and procedure codes do not align appropriately, the claim will be denied.
For example, if we bill a procedure code for mental health services but use a diagnosis code that represents foot pain, the claim will be denied because the procedure and diagnosis do not align with each other.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists or use reliable websites to determine whether the diagnosis is appropriate with procedure or not.
If the coding team confirms that the diagnosis is appropriate, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct coding).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO12 denial code description and corrective action
Diagnosis code is inconsistent with Provider's type/specialty/taxonomy.
Description
This denial occurs when the diagnosis code is not compatible with provider's specialty, taxonomy..
Each provider has a specialty in a specific field of medicine, such as cardiology, podiatry, physical therapy, or psychology etc. If a diagnosis code used that does not fall within the provider’s specialty, the claim will be denied with this denial code.
For example, if the provider is a podiatrist and we use diagnosis of mental health, then the claim will be denied because the diagnosis do not fall under the provider’s specialty.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 or history of any other patient with the same coding (diagnosis) and billed under same provider, have been paid, then we 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.
We also check all provider information used in the claim is accurate or not. If we found something wrong then we submit corrective claim with correct provider's information.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
Consult coding specialists or use reliable websites to determine whether the diagnosis is appropriate with provider's specialty or not..
If the coding team confirms that the diagnosis can be used under respective provider, then we proceed with submitting an appeal.
If we determine that the denial is accurate and the coding team suggests the correct diagnosis, then we submit a corrected claim (or a new claim if the payer is Medicare). However, if the denial is accurate and there is no alternate diagnosis suggested by the coding team, we contact the client to inform them that the mentioned diagnosis cannot be billed under their specialty. After that, we proceed according to the provider’s instructions.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO13 denial code description and corrective action
Date of death precedes the date of service.
Description
This denial occurs when the date of death (DOD) is earlier than the date of service (DOS).
It is not practically possible in real life, and most often this denial occurs due to an error—either in entering the date of service (DOS) during billing or in the date of death (DOD) recorded on the insurance side.
For example, if we submit a claim with a date of service (DOS) of 06/05/2024 while the insurance records show the date of death (DOD) as 06/04/2024, the claim will be denied because the DOD is earlier than the DOS.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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.
Confirm the date of service (DOS) and date of death (DOD) by reviewing the patient’s medical records and supporting documents.
Call the insurance company to verify the DOS and DOD as recorded on their end. If the DOS and DOD are the same, or if the DOS is earlier than the DOD, request the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and then follow up on the claim after the turnaround time (TAT) provided.
If the DOD precedes the DOS according to the insurance data, but our records confirm that the DOS is accurate, then we submit an appeal with the necessary documents to prove that the patient was alive on the mentioned DOS and that the provider rendered the services.
If the claim DOS was entered incorrectly by the biller, then we submit a corrected claim with the accurate DOS. In this case, we can either submit a new claim with the correct DOS or make a DOS correction and void the claim that was submitted with the wrong DOS.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO14 denial code description and corrective action
Date of service precedes the date of birth.
Description
This denial occurs when the date of service (DOS) on claim is earlier than the date of birth (DOB).
It is not practically possible in real life, and most often this denial occurs due to an error—either in entering the date of service (DOS) or date of birth (DOB) during billing or in the date of birth (DOB) recorded on the insurance side.
For example, if we submit a claim with a date of service (DOS) of 06/04/2024 while the insurance records show the date of birth (DOB) as 06/05/2024, the claim will be denied because the DOS is earlier than the DOB.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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.
Confirm the date of service (DOS) and date of birth (DOB) by reviewing the patient’s medical records and supporting documents.
Call the insurance company to verify the DOS and DOB as recorded on their end. If the DOS and DOD are the same, or if the DOB is earlier than the DOS, request the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and then follow up on the claim after the turnaround time (TAT) provided.
If the DOS precedes the DOB according to the insurance data, but our records confirm that the DOS is accurate, then we submit an appeal with the necessary documents to prove the correct DOB and also services rendered on DOS.
If the claim DOS or DOB was entered incorrectly by the biller, then we submit a corrected claim with the accurate dates.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO16 denial code description and corrective action
Claim lacks information or has billing/ submission error.
Description
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 claim 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.
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.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO18 denial code description and corrective action
Exact duplicate claim/service.
Description
This denial mostly occurs when we bill same service/claim of the same date of service more than one time.
Sometime we bill the claim twice in error then we receive this denial. In this case the first one processed while the other one denied as duplicate of the first one.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 if the claim was billed twice by mistake, obtain the status of the original claim and proceed accordingly.
Sometimes the procedure is the same but has a different modifier, provider, or visit time. In such cases, we discuss this with the representative and request reprocessing of the claim. Be sure to note the claim number, the representative’s name, and the call reference number, and then follow up on the claim after the provided TAT.
If the patient visited twice on the same day but we did not append a modifier to indicate the second visit, the representative will deny reprocessing. In this case, we need to submit a corrected claim with the required modification (modifier).
If the patient visited twice, the coding is correct, and the representative does not agree to reprocess the claim, then we proceed with submitting an appeal along with the necessary supporting documents to justify the services.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO19 denial code description and corrective action
This is a work related injury/illness, so liability of worker compensation.
Description
This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to worker’s compensation.
Sometimes, even if the illness is not work-related, using an incorrect diagnosis that indicates a work-related injury can also lead to this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 information about worker’s compensation, if available. If the representative has the worker’s compensation details, then obtain all the necessary information. If not, then check history and documents or contact patient for worker compensation details.
Enter the worker’s compensation information as the primary insurance and bill the claim to worker’s compensation.
Do not keep the commercial payer as secondary, except in the case of Medicare. If worker’s compensation leaves any amount as the patient’s responsibility, bill it to Medicare by updating the MSP code.
If the patient documents show that the illness is not related to worker’s compensation, consult the coding team to review the coding. There may be a chance that an incorrect diagnosis code was used, which indicated the illness as work-related and resulted in the denial. If that is the case, submit a corrected claim, and for Medicare, submit a new claim.
CO20 denial code description and corrective action
This injury/illness is covered by the liability carrier.
Description
This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to liability carrier.
Sometimes, even if the illness is not related to liability carrier, using an incorrect diagnosis that indicates a liability carrier related injury and can also lead to this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 information of liability carrier, if available. If the representative has the liability carrier details, then obtain all the necessary information. If not, then check history and documents or contact patient for liability carrier details.
Enter the liability carrier information as the primary insurance and bill the claim to liability carrier.
Do not keep the commercial payer as secondary, except in the case of Medicare. If liability carrier leaves any amount as the patient’s responsibility, bill it to Medicare by updating the MSP code.
If the patient documents show that the illness is not related to liability carrier, consult the coding team to review the coding. There may be a chance that an incorrect diagnosis code was used, which indicated the illness related to liability carrier and resulted in the denial. If that is the case, submit a corrected claim, and for Medicare, submit a new claim.
CO21 denial code description and corrective action
This injury/illness is liability of no-fault carrier.
Description
This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to np-fault carrier.
Sometimes, even if the illness is not related to no-fault carrier, using an incorrect diagnosis that indicates a no-fault carrier related injury and can also lead to this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 information of no-fault carrier, if available. If the representative has the no-fault carrier details, then obtain all the necessary information. If not, then check history and documents or contact patient for no-fault carrier details.
Enter the no-fault carrier information as the primary insurance and bill the claim to no-fault carrier.
Do not keep the commercial payer as secondary, except in the case of Medicare. If no-fault carrier leaves any amount as the patient’s responsibility, bill it to Medicare by updating the MSP code.
If the patient documents show that the illness is not related to no-fault carrier, consult the coding team to review the coding. There may be a chance that an incorrect diagnosis code was used, which indicated the illness related to no-fault carrier and resulted in the denial. If that is the case, submit a corrected claim, and for Medicare, submit a new claim.
CO22 denial code description and corrective action
This care may be covered by another payer as per coordination of benefits (COB).
Description
Coordination of benefits refers to the process used by insurance companies to determine the order (primary, secondary, tertiary) in which multiple insurance plans will pay for a patient’s healthcare services. When a patient is covered under more than one insurance policy, COB ensures that payments are coordinated properly.
This denial mostly occurs when a patient has more than one insurance plan but has not updated their coordination of benefits (COB) with the insurance company.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 details of the primary payer, if available. If the representative has the information, obtain all the necessary details such as insurance name, policy number, payer ID, and effective period. Once confirmed, bill the claim to that insurance after verifying the eligibility and make current insurance as secondary.
If the insurance information provided by the representative is not active on the DOS, request the representative to reprocess the claim since there is no active other insurance. Be sure to note the claim number, processed date, call reference number, and representative’s name, and follow up on the claim after the provided TAT.
If the representative has no information about the primary insurance, check the supporting documents and member history to identify the primary payer. If no details are found, contact the member to obtain the primary insurance information, and then bill the claim to the primary insurance after verifying eligibility and make current insurance secondary.
Sometimes both insurances deny the claim with the same COB reason. In such cases, contact the member and ask them to update their COB with the insurances and inform us once it is updated so the claim can be processed. If the member does not respond, then bill the claim to the patient.
CO23 denial code description and corrective action
Impact of prior payer including payments and adjustments.
Description
This denial mostly comes from the secondary insurance.
This denial occurs when the primary insurance payment is equal to or greater than the secondary insurance’s allowed amount. Let’s understand this with example.
Let us consider an example where the primary insurance allows $50, pays $40, and leaves $10 as coinsurance. The secondary insurance also allows $50, so it pays the remaining $10 coinsurance.
If the secondary insurance allows $45, then it will pay $5 and adjust the remaining $5 with code CO23.
If the secondary insurance allows $40 or less, then it will not pay anything and will adjust the full $10 coinsurance amount with code CO23.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Check if the secondary allowed amount is equal to the sum of the primary payment and the secondary payment. If yes, then the amount adjusted with CO23 should be written off.
If the secondary allowed amount is more than the sum of the primary and secondary paid amounts, then contact the insurance company and request the representative to reprocess the claim. Be sure to note the claim number, processed date, call reference number, and representative’s name, and then follow up on the claim after the provided TAT.
If the denial comes from the primary insurance, we must call the insurance company to find out the exact reason for the denial since there is no other prior payer. Discuss the details with the representative and then proceed accordingly.
CO24 denial code description and corrective action
Charges are covered under capitation agreement/ managed care plan.
Description
Capitation is an agreement between a provider and a payer in which the payer pays a fixed amount to the provider per patient for a specific period of time, regardless of the number or cost of services the patient receives. This means a patient may receive many services or very few, but the payment to the provider remains the same.
This denial occurs when the patient is covered under a capitation agreement, or when payment has already been made to the provider under the per-capitation arrangement.
There is a list called the capitation list, which shows the names of patients covered under the capitation agreement.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 discuss the denial with the representative. If the DOS falls outside of the capitation period or if the patient is not found on the capitation list, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
If the patient is found on the capitation list and the DOS also falls within the capitation agreement period, then write off the claim since it is already paid under capitation.
If this denial is received from Medicare or Medicaid, then it is not related to capitation. Instead, it indicates that the claim is associated with a managed care plan.
In this case, review the patient’s history and documents, call the insurance, check the portal, or contact the member to obtain the managed care insurance information.
After finding the information, bill the claim to the managed care plan as the primary insurance. Do not keep Medicare or Medicaid as secondary, as they will not pay this claim and will again deny it with the same denial reason if billed as secondary.
In the case of Medicaid, we can bill the claim to the managed care plan using the Medicaid ID, except for BCBS-managed plans.
CO26 denial code description and corrective action
Expenses incurred prior to the coverage start.
Description
This denial occur when the date of service lies before the coverage start date of insurance.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 discuss the denial with the representative. If the policy is found to be active on the DOS, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
If the DOS is earlier than the coverage start date, ask the representative to check their records to see if there was any active policy on the DOS. If a policy is found, resubmit the claim with the new policy ID after verifying eligibility.
If no active policy is found, review the patient’s history and documents, check the portal, or contact the member to obtain the active insurance on the DOS. If active insurance is found, then resubmit the claim with that insurance after verifying eligibility.
If there is no active insurance on the DOS, then bill the claim to the patient.
CO27 denial code description and corrective action
Expenses incurred after coverage terminated.
Description
This denial occur when the date of service lies after the coverage terminated date.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 discuss the denial with the representative. If the policy is found to be active on the DOS, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
If the DOS is after the policy terminated date, ask the representative to check their records to see if there was any active policy on the DOS. If a policy is found, resubmit the claim with the new policy ID after verifying eligibility.
If no active policy is found, review the patient’s history and documents, check the portal, or contact the member to obtain the active insurance on the DOS. If active insurance is found, then resubmit the claim with that insurance after verifying eligibility.
If there is no active insurance on the DOS, then bill the claim to the patient.
CO29 denial code description and corrective action
The time limit for filing has expired.
Description
This denial occurs when a claim or appeal is submitted to the insurance company after the timely filing limit has expired.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 discuss the denial with the representative. If the claim is found to have been billed within the timely filing limit, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
If the claim is denied due to the timely filing limit (TFL) being expired but proof of timely filing (POTF) is available, 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.
Sometimes a claim is mistakenly billed to the wrong insurance, and after receiving the denial, it is then billed to the correct insurance, but by that time the timely filing limit of the new insurance has expired. In this case, we can use the proof of timely filing (POTF) from the first submission and proceed with submitting an appeal.
Sometimes a claim is billed on the last day of the filing limit, but the insurance receives it a day later and denies the claim. In this case, we submit an appeal with proof of timely filing (POTF).
If a claim or appeal was truly billed after the timely filing limit and no proof of timely filing (POTF) is available, then we proceed according to the practice SOPs in this case, which most often means writing off the claim.
CO31 denial code description and corrective action
Patient cannot be identified as our insured.
Description
This denial occurs mostly when we billed claim with incorrect patient name, gender or DOB.
Actions
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 ask the representative to search for the patient using their name, date of birth (DOB), or Social Security Number (SSN).
If the patient is found, confirm the correct member ID associated with the patient and also verify the effective coverage period.
If the claim is found under this ID, then proceed according to the claim status. Never forget to get correct claim number.
If the claim is not found, then after verifying the timely filing limit and confirming that the insurance was active on the DOS, rebill the claim using the correct member ID.
If the member is found but coverage is shown as inactive on the DOS, try to obtain the active policy from available resources such as member history, documents, or by contacting the member. If an active policy is found, then after verifying eligibility and the timely filing limit, bill the claim to the new insurance.
If no active policy is found, then release the claim to the member.
Sometimes an incorrect name, DOB, or gender is used. After verifying the correct information with the insurance representative or portal, rebill the claim with the updated details.
Always use the most updated format of the member ID provided by the insurance, and never forget to include any required prefix in the ID, such as with BCBS.
CO45 denial code description and corrective action
Charges exceed the fee schedule/ maximum allowable or contracted fee agreement.
Description
This is basically an adjustment and occurs when the charge amount exceeds the maximum allowable limit or the contracted fee schedule.
A fee schedule refers to the predetermined list that defines how much a procedure should be allowed or reimbursed by the insurance.
For example, let us consider that the contracted amount for a procedure is $80. This means that if the claim is not denied, the allowed amount should be $80. If we bill that procedure with a charge amount of $150 without any error, the insurance will allow $80 and adjust the remaining $70 with this remark code.
For out-of-network (OON) providers, denial code 45 may also come with category PR. This does not mean the amount should be billed to the patient. In most cases, we adjust it, or if the client has specific SOPs related to this situation, we proceed accordingly.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
If the claim is processed and paid, or processed as copay, coinsurance, or deductible, then the amount associated with this code should be written off.
When there is no paid amount or patient responsibility, and another denial code appears along with this code, disregard this code and work on resolving the other denial mentioned.
If there is neither a paid amount nor patient responsibility and the total amount is adjusted with this code, then we must contact the insurance company to obtain the exact reason for the denial.
If the representative provides the exact reason, then proceed accordingly based on the information given.
If the representative also does not have any information about the exact denial reason, then ask them to send the claim back for reprocessing since no clear denial reason is available. Be sure to note the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
CO49 denial code description and corrective action
Non covered services as it is a routine/ preventive exam or a diagnostic/ screening procedure done in conjunction with a routine/ preventive exam.
Description
This denial occurs when a claim is billed with routine diagnosis codes (diagnosis code start with Z).
It can be resolved by changing routine diagnosis with another proper diagnosis code.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Consult coding specialists to verify whether the diagnosis is appropriate.
If they provide the correct diagnosis code, submit a corrective claim with the updated diagnosis.
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 the coding is accurate, the claim becomes the member’s responsibility, as the routine service is not covered under their plan.
In this case, we will attempt to obtain information about the secondary insurance, and if found, verify eligibility and bill the claim to the secondary payer.
If no other active insurance is present for this date of service, release the claim to the patient.
Sometimes the client requests that we submit an appeal before releasing the claim to the member; in such cases, proceed accordingly.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO50 denial code description and corrective action
Non covered services because this is not deemed as medical necessity by the payer.
Description
This denial occurs when the insurance does not consider the services provided to be medically necessary based on the patient’s health condition.
Sometimes, an incorrect diagnosis code is appended, which can also lead to this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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.
Consult coding specialists to verify whether the diagnosis is appropriate.
If they provide the correct diagnosis code, submit a corrective claim with the updated diagnosis.
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 the coding is accurate we proceed to submitting an appeal along with supporting documents and medical notes.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO51 denial code description and corrective action
Non covered services because this is a pre-existing condition.
Description
If a person wants to purchase a new insurance policy while already suffering from a disease, the insurance may refuse to cover services related to that condition. This existing disease is considered a pre-existing condition.
Some plans may provide coverage, but they often come with higher premiums and may include a waiting period.
A waiting period means that the insurance will cover these services only after a specified time, such as six months from the policy’s effective date. If a service is billed within the waiting period, it 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 claim status through the insurance web portal or by calling the payer.
Call the insurance company to confirm whether the service is not covered or denied because the date of service falls within the waiting period.
If the service is covered and the date of service falls after the waiting period, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and follow up on the claim after the provided turnaround time (TAT).
If the service is not covered or the date of service falls within the waiting period, it becomes the patient’s responsibility. In this scenario, bill the claim to the patient, as the secondary insurance will not pay.
If there is any other active primary insurance, bill the claim to that insurance before releasing it to the member.
CO55 denial code description and corrective action
Procedure/ treatment/ drug is deemed as experimental/ investigational by the payer.
Description
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 claim 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/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/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.
CO96 denial code description and corrective action
Non covered charges.
Description
This denial falls into two categories.
Non-covered charges as per the patient’s plan.
This occurs when either the provider is out-of-network (OON) or the diagnosis (DX) or procedure code (CPT) is not covered under the member’s plan.
Non-covered charges as per the provider contract.
This occurs when the procedure is not covered under the provider’s contract.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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.
Confirm with the representative whether the service is not covered under the member’s plan or the provider’s contract.
If it is non-covered under the member’s plan, obtain specific information to determine whether the denial is due to the provider’s status with the insurance, a non-covered diagnosis, or a non-covered procedure.
If the denial is due to the provider being out-of-network (OON), then click here for further steps.
If the diagnosis (DX) or procedure code (CPT) is not covered, assign the claim to the coding team to suggest an alternate DX or CPT.
If they provide an alternate CPT or diagnosis code, submit a corrective claim with the updated coding.
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 or diagnosis, bill the claim to the secondary insurance after verifying eligibility. If there is no active secondary insurance, release the claim to the patient.
If the service is not covered under the provider’s contract and no payment has been received in the past for the same services, proceed by either submitting an appeal or writing it off as per practice SOPs.
CO97 denial code description and corrective action
Benefits for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Description
This denial occur when insurance considered a service as a part of other service so denied as benefit for this service has already been adjudicated with another service.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Call to insurance and get proper information of the denied procedure and also the information of procedure to which it is bundled. Also if we have paid claim in member's history with same coding then we ask rep to reprocess the claim. Must note the rep name, claim number and call ref number and follow back claim after TAT provided.
Share this claim to coding team to check if claim could be reimbursed by updating some modifier. We can also use reliable websites to check NCCI edit either these services could be billed together or not and if yes either they required modifier or not. It also provide most suitable modifier to override.
If the services can be billed together and a modifier is identified either through reliable websites or the coding team, submit a corrective claim with the required modification.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
If the services cannot be billed together according to NCCI edits, then the charges should be written off.
If the coding team confirms that the coding is correct and the services can be billed together, then either contact the insurance to request reprocessing of the claim or proceed with submitting an appeal.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
PR100 denial code description and corrective action
Payment made to patient, insured or responsible party.
Description
This denial mostly occurs when the patient has not signed the Assignment of Benefits (AOB).
An Assignment of Benefits (AOB) is an agreement between the member and the insurance company that allows the insurance to pay the provider directly for the patient’s healthcare services.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
If the claim is paid to the patient, then the bill should be sent directly to the patient.
Do not bill the secondary or any consecutive payer, as it is the patient’s responsibility to forward this amount to the provider.
Representatives and web portals do not provide payment details, such as the check number, when the AOB is not signed by the patient.
CO109 denial code description and corrective action
This claim/service not covered by this payer/contractor. You must send the claim/service to correct payer/contractor.
Description
This denial mostly occurs when we mistakenly bill claim to the wrong payer/ insurance but the primary insurance is another one.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 details of the primary payer, if available. If the representative has the information, obtain all the necessary details such as insurance name, policy number, payer ID, and effective period. Once confirmed, bill the claim to that insurance after verifying the eligibility and make current insurance as secondary.
If the insurance information provided by the representative is not active on the DOS, request the representative to reprocess the claim since there is no active other insurance. Be sure to note the claim number, processed date, call reference number, and representative’s name, and follow up on the claim after the provided TAT.
If the representative has no information about the primary insurance, check the supporting documents and member history to identify the primary payer. If no details are found, contact the member to obtain the primary insurance information, and then bill the claim to the primary insurance after verifying eligibility and make current insurance secondary.
CO119 denial code description and corrective action
Benefit maximum for this period or occurrence has been reached.
Description
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 claim 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.
CO129 denial code description and corrective action
Prior processing information appears incorrect.
Description
This denial is mostly received from secondary or consecutive payers and occurs for two reasons.
Primary insurance did not pay the claim.
Primary insurance paid the claim, but the payment information submitted on the claim form to the secondary insurance is incorrect.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 denial. If the primary has paid the claim and the payment information (Box #29 on the CMS-1500 form and Box #54 on the UB-04 form) is found to be correct, 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 primary has paid the claim and the information on the claim form submitted to the secondary is incorrect, correct the information and rebill the claim. Also, review the payment information on the new claim, and if it still appears incorrect, mail or fax the claim to the insurance.
If the primary did not pay the claim and it was billed to the secondary, resulting in this denial, then the next step is to work on resolving the primary denial.
Only a few primary denials such as non-covered services under the patient’s plan, maximum benefits reached, and other PR (Patient Responsibility) denials may be considered for payment by the secondary, depending on the member’s plan type.
CO140 denial code description and corrective action
Patient/insured health identification number (member ID) or name mismatch.
Description
This denial occurs mostly when we billed claim with incorrect patient/insured name, or member ID.
Actions
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 ask the representative to search for the patient using their name, date of birth (DOB), or Social Security Number (SSN).
If the patient is found, confirm the correct member ID associated with the patient and also verify the effective coverage period.
If the claim is found under this ID, then proceed according to the claim status. Never forget to get correct claim number.
If the claim is not found, then after verifying the timely filing limit and confirming that the insurance was active on the DOS, rebill the claim using the correct member ID.
If the member is found but coverage is shown as inactive on the DOS, try to obtain the active policy from available resources such as member history, documents, or by contacting the member. If an active policy is found, then after verifying eligibility and the timely filing limit, bill the claim to the new insurance.
If no active policy is found, then release the claim to the member.
Sometimes an incorrect name, DOB, or gender is used. After verifying the correct information with the insurance representative or portal, rebill the claim with the updated details.
Always use the most updated format of the member ID provided by the insurance, and never forget to include any required prefix in the ID, such as with BCBS.
CO146 denial code description and corrective action
Diagnosis code is invalid for the DOS reported.
Description
This denial occurs when the insurance considers the diagnosis code billed was invalid for date of service (DOS) reported.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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 insurance representative which diagnosis is invalid, especially if multiple diagnoses were used.
Consult coding specialists to determine whether the diagnosis code is appropriate or not.
If the coding team confirms that the diagnosis is appropriate with DOS then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct diagnosis).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO150 denial code description and corrective action
Payer deems the submitted information does not support this level of service.
Description
This denial mostly occurs due to coding issues (medical necessity).
Sometimes, reaching the maximum benefits for a service may also cause this denial.
Sometimes, this denial may also occur if the insurance requires medical records to support the service.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 confirm the exact denial reason and proceed accordingly.
If the claim is denied due to a coding issue (medical necessity), then click here for further steps.
If the claim is denied because the maximum benefits have been reached, then click here for further steps.
If the claim is denied because the insurance requires supporting data (medical records), then click here for further steps.
CO151 denial code description and corrective action
Payer deems the information submitted does not support this many/frequency of services.
Description
This denial occurs when a procedure is billed more times than allowed under the reimbursement guidelines.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 confirm the reimbursement guidelines for this procedure. These guidelines define the limitation on the number of units that can be billed within a certain time period (e.g., once per day, once per year, etc.). After confirming, verify in your system whether the claim was billed according to the guidelines or if it exceeded the allowable limits.
If the claim is found to have been billed according to the guidelines, 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 turnaround time (TAT).
If the procedure has already been paid up to the maximum allowed according to the insurance guidelines, but no such claim is found in our system, obtain the information from the representative along with the provider details on the claim. It is possible that the charge was not posted in our system or that the claim was billed by another provider. If the procedure and provider information provided by the representative match the notes, then the denial is considered correct. In such cases, contact the client to discuss and proceed as per their direction. The client may request to submit an appeal or write off the charge.
If the procedure has already been paid up to the maximum allowed according to the guidelines and is also present in our system, follow the practice SOPs and proceed accordingly.
CO163 denial code description and corrective action
Attachment or other document referenced on the claim was not received.
Description
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 claim 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.
CO181 denial code description and corrective action
Procedure code was invalid on the date of service.
Description
This denial occurs when the insurance considers the procedure code billed was invalid for date of service (DOS) reported.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists to determine whether the procedure code is appropriate or not.
If the coding team confirms that the procedure is appropriate with DOS then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct procedure).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO182 denial code description and corrective action
Modifier was invalid on the date of service.
Description
This denial occurs when the insurance considers the modifier used was invalid for date of service (DOS) reported.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists to determine whether the modifier is appropriate or not.
If the coding team confirms that the modifier is appropriate then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct modifier).
Sometimes, when the same procedure is billed on two separate lines with LT and RT modifiers, the insurance pays for one line but denies the other with this code. In such cases, a corrected claim should be submitted by billing the procedure with a 50 modifier on a single line, doubling the charge amount, and removing the second line.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO183 denial code description and corrective action
Referring provider is not eligible to refer for the service billed.
Description
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 claim 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/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO185 denial code description and corrective action
Rendering provider is not eligible to perform for the service billed.
Description
This type of denial most often occurs when the rendering provider’s specialty is different.
It also may occur when the rendering provider is not enrolled with the insurance or group.
Sometimes it also may occur when the rendering 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 claim 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 rendering provider’s specialty is different, consult the client to obtain the exact details of the rendering provider and proceed according to the action suggested by the client.
If the rendering 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 rendering 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 rendering 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/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO197 denial code description and corrective action
Precertification/authorization/pre-treatment/notification absent.
Description
For certain medical treatments, the provider needs to obtain approval from the insurance company, which is referred as authorization, notification, pre-treatment, or precertification.
This denial may occur if the services provided require authorization but were not obtained from the insurance.
It may also occur if the auth# entered on the claim is invalid, either for the date of service (DOS) or for the services billed.
Sometimes this denial also occurs if the provider is out-of-network and the patient does not have out-of-network benefits, in which case every service requires authorization. In such situations, we proceed according to the denial stating that services are not covered by out-of-network providers (CO242).
There are two types of authorization: prior authorization (obtained before the services are performed) and retro authorization (obtained after the services are performed).
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 ask representative to check if authorization is present in their system and if authorization is present and also effective for the billed DOS and services the 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.
If auth is available but rep deny to reprocess claim then we proceed to submitting corrected claim with this authorization.
If auth is not available in system and services performed is an emergency service then request the representative to reprocess the claim, note the necessary details, and follow up on the claim after the given TAT.
If auth is not available and service is also not emergency then ask rep if retro authorization is possible to obtain, then follow the procedure rep told to get retro authorization. And if retro auth is also not possible to obtain then claim should be written off but some clients want us to submit an appeal, so proceed accordingly.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO199 denial code description and corrective action
Revenue code and procedure code do not match.
Description
This denial occurs when the procedure code billed is not compatible with the revenue code.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, 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.
Consult coding specialists to determine whether the revenue code is appropriate with procedure or not.
If the coding team confirms that the procedure and revenue code are appropriate, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct coding).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO226 denial code description and corrective action
Information requested from the billing/rendering provider was not provided, or not provided timely or was insufficient/incomplete.
Description
This denial is related to medical records and supporting documentation for the claim.
It mostly occurs when the requested medical records are not provided, or they are submitted after the allowed time.
Sometimes this denial occurs when medical records are submitted but do not fully support the service, or when the records are incomplete.
The absence of the provider’s signature from the records can also lead to this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 exactly what is required to process the claim, or if records were already submitted, confirm what specific information is missing. If it is found that all the required information has already been received, ask the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and then follow up on the claim after the given TAT.
If the representative confirms the exact document required, submit that document. If the document is not available in our system, ask the client to provide it so we can proceed further.
Make sure the time limit for submitting records has not been exceeded. If it has, the claim needs to be written off. However, some providers still wants the documents to be sent even after the limit has passed, then we proceed accordingly.
Sometimes, along with this denial code, there is a remark code that clearly indicates what the insurance requires, so proceed accordingly.
Never forget to check the provider’s signature on the medical records.
If all required records have already been submitted but the insurance still denies the claim and rep disagree to send back for reprocess, then we proceed with submitting an appeal along with the complete documents to support the service.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO227 denial code description and corrective action
Information requested from patient/insured/responsible party was not provided or was insufficient/incomplete.
Description
This denial is related to information requested from the patient, such as Coordination of Benefits (COB) or other required details.
It mostly occurs when the requested information is not provided.
When the insurance requests information from the patient, they send a letter to the patient regarding that information.
If the provided information is not sufficient to meet the insurance requirements, it can also cause this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Call the insurance company and discuss the denial. If it is confirmed that all the required information has already been received, ask the representative to reprocess the claim. Be sure to record the claim number, representative’s name, and call reference number, and then follow up on the claim after the given TAT.
If COB or other information is required from the patient and a letter has already been sent recently, then we will wait up to 15 to 30 days for the patient’s response.
If the insurance has sent a letter and 30 or more days have passed, then bill the claim to the patient or contact the client for further instructions.
If the insurance has not yet sent a letter, then we should ask the representative to send one for the required information and also try to contact the member directly to tell member to update the specific information with the insurance.
If the requested information is COB, click here for further details.
CO234 denial code description and corrective action
This procedure is not paid separately.
Description
There are certain procedures that cannot be billed alone and require a primary procedure code for reimbursement. If the procedure is billed without the primary procedure, or if the wrong primary procedure is used, this denial is received.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Call the insurance company to obtain information about the primary procedure code. If it is found that we already billed the procedure along with the primary procedure code, or if there is a paid claim in the member’s history with the same coding, then ask the representative to reprocess the claim. Be sure to note the representative’s name, claim number, and call reference number, and follow up on the claim after the provided TAT.
If the representative does not provide the primary procedure code, then contact the coding team to review the coding.
If the coding team provides the correct primary procedure code and it is not present in the system, then resubmit the claim with both procedures.
If the coding team confirms that the coding is correct and the procedure can be billed alone, but the representative still refuses to reprocess the claim, then we proceed with submitting an appeal.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO236 denial code description and corrective action
Procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to national correct coding initiative or worker compensation state regulations or fee schedule requirements.
Description
For the use of modifiers, we must keep in mind their proper combination with the CPT code. If a modifier is not appropriate or does not align with the procedure code, the claim may be denied with this denial code.
This denial is related to coding.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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, and ask the representative to reprocess the claim. Be sure to note the claim number and call reference number, and then follow up on the claim after the provided TAT.
Consult coding specialists to review the coding and determine if there is any alternate modifier or procedure that can be used.
We can also use websites to check NCCI edits.
If the coding team confirms that the coding is correct, then we proceed with submitting an appeal.
If we determine that the denial is accurate, then we submit a corrected claim with the required modifications (correct coding).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
CO242 denial code description and corrective action
Services not provided by network/ primary care physician. (Services provided by OON provider).
Description
This denial occurs when the provider is not contracted with the insurance.
The basis of this denial is that the provider is out-of-network (OON) while the patient’s plan does not cover OON benefits.
Plan types like HMO and EPO do not offer OON benefits, while PPO and POS plans do provide OON benefits.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 the patient’s plan type and benefits. If the plan covers OON benefits and the provider is also OON, then 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.
Also check the provider’s status, and if the provider is found to be in-network (INN) on the date of service (DOS), then ask the representative to reprocess the claim. Be sure to document the important details and follow up after the provided TAT.
If the provider is OON and the patient has no OON benefits, then bill the claim to the secondary insurance, if available, after verifying eligibility.
If there is no other active insurance, then release the claim to the patient.
CO252 denial code description and corrective action
Missing document. An attachment is needed to process the claim.
Description
This denial occurs when the insurance requires documentation to process the claim.
This denial mostly occurs when the insurance requires medical records to validate the services.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Mostly, there may be a remark code that specifies what information is required. If not, we should contact the insurance to confirm the exact reason for the denial. If it is found that the required document has already been submitted and received by insurance, then ask the representative to reprocess the claim. Be sure to record the claim number, representative’s name, and call reference number, and follow up on the claim after the provided turnaround time (TAT).
If the document has not yet been sent and we have it in our system, then we send it through mail or fax. Since most insurance portals now allow submission of records online, we can also use this feature to submit the documents.
If we do not have access to the document, then we contact the client to provide it so we can proceed further.
Also check the time limit for submitting the document, and if it has been exceeded, follow the practice’s SOPs. Some clients may still want us to submit the document even after the limit has passed, so we should proceed according to their instructions.
CO288 denial code description and corrective action
Referral absent.
Description
Referral is a recommendation to a patient from Primary Care Physician to receive medical services from another health care provider or medical specialist.
In some plans, such as HMOs, a referral from the PCP is necessary to visit a specialist, and if it is not present, the insurance denies the claim with this denial code.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 the patient’s plan type and whether a referral is required for the services. If a referral is not required and the claim was denied in error, 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 a referral is required, check whether it was entered on the claim. If it was entered, ask the representative to verify whether the referral is present on their side. If it is present, request the representative to reprocess the claim. Be sure to note the claim number, representative’s name, and call reference number, and follow up on the claim after the provided TAT.
If we submitted the referral but the insurance did not receive it, this would be a system glitch. In this case, we resubmit the claim and check again if the referral is updated on the new claim. If it is still not updated, we submit the claim through fax or mail.
If a referral is required but not present, then we proceed according to the client’s instructions (write-off or appeal).
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
B7 denial code description and corrective action
Provider was not eligible/certified to be paid for this procedure/service on this DOS.
Description
This denial mostly occurs when the provider is not eligible to perform the billed services on the mentioned DOS.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer.
Call the insurance company to confirm the exact denial reason and proceed accordingly.
If the claim is denied because the rendering provider’s specialty is different, then click here for further steps.
If the claim is denied because the rendering provider is not eligible to perform the services, then click here for further steps.
If the claim is denied because the referring provider is not eligible to refer for this service, then click here for further steps.
If the representative provides any other denial cause, then proceed accordingly.
B9 denial code description and corrective action
Patient enrolled in a hospice.
Description
When a patient is diagnosed with a disease that cannot be treated, or with a disease that could be treated but the patient refuses treatment due to its life-threatening nature, and the patient has a life expectancy of less than six months, then the patient becomes eligible for hospice.
If hospice care is chosen, the patient receives only pain relief and comfort measures, not curative treatment for the disease.
In hospice billing, modifiers such as GV and GW are used.
GV: Used when the provider is not related to hospice but is providing services for a hospice patient.
GW: Used when the provider is related to hospice but is providing services that are not related to hospice care.Hospice claims are billed to Medicare Part B or hospice plan.
This denial occurs when the claim is related to hospice care but is billed to a commercial payer.
It may also occur when hospice-related modifiers are not used.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 whether the date of service (DOS) falls within the hospice enrollment period. If the DOS is earlier than the hospice enrollment period, ask the representative to reprocess the claim. Be sure to document the claim number, representative’s name, and call reference number, and then follow up on the claim after the provided TAT.
If the DOS falls within the hospice period and the representative provides the hospice plan information, update the plan as primary and bill the claim.
We can also use the Medicare portal and the NPPES website to find hospice information.
If the representative does not provide any information, then check the documents or contact the member to obtain hospice information, and if found, submit the claim to hospice as primary.
If we are unable to obtain hospice information from any source, then we bill the claim to the member or proceed according to the SOPs of the practice and the client’s suggestion.
Commercial payer do not pay hospice claim.
B16 denial code description and corrective action
New patient criteria not met.
Description
If a patient visited the doctor within the last 3 years, then they would be considered an established patient. If more than 3 years have passed since the last visit, then they would be considered a new patient.
There are procedure codes that specifically differ based on whether the patient is new or established. If the patient is established and we bill a code for a new patient, then we get this denial.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 the last visit, or check our system to verify the patient’s last visit. If there is no other visit or if the last visit was more than 3 years ago, then ask the representative to reprocess the claim as it is now considered a new patient. Be sure to note the claim number, rep name, and call reference number, and then follow up on the claim after the provided TAT.
If it is found that the patient is not new and already had a visit within the last three years, then contact the coding team to suggest an alternate procedure code.
After receiving the coding response, submit a corrected claim with the required modifications (correct procedure).
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
B20 denial code description and corrective action
Procedure/service was partially or fully furnished by another provider.
Description
This denial occurs when multiple providers billed the same service on the same DOS.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 the information of the second claim having the same services billed for the same DOS. If the representative does not find any other claim, ask them to reprocess the claim as it was denied by mistake. Be sure to note the claim number, representative name, and call reference number, and then follow up on the claim after the provided TAT.
If the rep provides the information of the second claim, then we check our system to see whether the second claim is present or not.
If we also find the second claim in our system from another provider, then we submit a corrected claim with modifier 77.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
If we do not have the claim in our system and the provider on the second claim is not related to our group, then we proceed with submitting an appeal or follow practice SOPs or client suggestions.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
M119 denial code description and corrective action
Missing/incomplete/invalid/deactivated/withdrawn National drug code (NDC).
Description
NDC is required for drug procedure codes that start with alphabets, such as J7649.
This denial occurs when NDC is required but missing in the claim.
It may also occur when we use an outdated or wrong NDC.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 ask the representative to provide the correct NDC. If the rep provides the correct NDC and we also billed the claim with the same NDC, then ask the rep to verify the NDC present on the claim. If it is found that the claim is billed with the correct NDC, then 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.
If the rep provides the correct NDC but we billed either the wrong NDC or missed the NDC, then we submit a corrected claim with the updated NDC.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
If the rep does not provide the NDC, then we can also use Google to find the updated NDC.
If we are not able to find the correct NDC from any resource, then we contact the client for suggestions.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
MA120 denial code description and corrective action
Missing/incomplete/invalid CLIA certification number.
Description
This denial occurs when CLIA certification number is required but missing in the claim.
It may also occur when we use an outdated or wrong CLIA certification number.
Actions
First, we need to verify the status of the claim. This can be done by checking the claim 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 ask the representative to provide the correct CLIA certification number. If the rep provides the correct CLIA certification number and we also billed the claim with the same CLIA certification number, then ask the rep to verify the CLIA certification number present on the claim. If it is found that the claim is billed with the correct one, then 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.
If the rep provides the correct CLIA certification number but we billed either the wrong CLIA certification number or missed the CLIA certification number, then we submit a corrected claim with the updated CLIA certification number.
Medicare does not accept corrected claims, so in the case of any denial, a new claim must always be submitted.
If the rep does not provide the CLIA certification number, then we can also use portal like CMS and CDC to find CLIA number.
If we are not able to find the correct CLIA certification number from any resource, then we contact the client for suggestions.
For submitting an appeal/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/corrective claim even after the timely filing limit has passed, so we should proceed according to their instructions.
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