Denials Notes

1-COVERAGE EXHAUSTED (PR-26)

When the patient does not have coverage on the date of service Insurance deny the claim for coverage
Exhausted.

We will check eligibility on the website

1st Condition

If found insurance is active on the date of service

 We will call to insurance and ask the representative to send the claim back for reprocess.
 We will take turnaround time and call ref.

2nd Condition

If found the insurance not active on the date of service

 We will look for the other active insurance if found then we will bill to that insurance otherwise
we will bill to the patient.

Note: If patient is above 65 years patient will have Medicare. We also need to check whether patient
have Medicaid or not.

2-COVERED BY ANOTHER PAYER (CO-22)

When other insurance is primary on the date of service, we will get such kind of denial.

We will check eligibility on the website whether the insurance is primary or not.

1st Condition

If we found that, the same insurance is Primary from which we received the denial than we will call to
insurance, inform the representative that they are primary for dos, and ask the representative to
reprocess the claim.

We will take a turnaround time and call Reference.

2nd Condition

 If found the other insurance is Primary than we will update correct insurance as Primary and bill
to that Insurance.
 If we found conflicts between two insurance than we will send a statement to the patient for
COB update.
3-INCLUSIVE/BUNDLED (CO-97)

When the payment of one CPT is included in the payment of other CPT we get such kind of denials.

We will check on Encoder Pro/CCI Edit whether CPT are inclusive or not

If found CPT is inclusive, we will send the claim for coding review.

 If found CPT is not inclusive, we need to call insurance and ask a representative to reprocess the
claim.
 We will take a turnaround time and call Reference.

The modifier used in inclusive denial:

1. 59-Distinct Procedure Service

2. 25-Significiant, Separately Identifiable Evaluation and Management.

Note: If the CPT are not inclusive we can also appeal with medical Record, Screen Shot of Encoder Pro
and EOB.

4-NON COVERED SERVICES (CO-96 AND PR-96)

When the services are not covered under the patient’s plan or Provider specialty we will get such kind of
denials.

We will call to insurance and ask Denial Date and Claim Number.

 We will verify whether service is not covered under the patient plan or provider specialty and
we will take the reason for the same.
 We will take call Reference#

Action-

 If Service is not covered under the Doctor Specialty we will check whether same CPT has been
previously paid or not. If it has been previously paid then we will call to insurance and ask the
rep to send claim back for reprocess If previously it has not been paid then we will work as per
client protocol.
 If service is not covered under patient plan then we will check whether same CPT has been
previously paid or not. If it has been previously paid then we will call to insurance and ask the
rep to send claim back for reprocess and if it is not previously paid then we will bill the claim to
patient or any other active insurance.
5-DUPLICATE (CO-18)

If the same service is billed two time or the same service is performed two times and billed without
modifier insurance will deny the claim for Duplicate.

 We need to check in our system whether we have billed the same claim twice or not-:
 If we found the same service is performed twice we will write-off the duplicate claim.
 If we found the same service is performed twice and billed without modifier we will send the
claim to coding to append modifier.

1. Modifier 76 if the same service is performed by the same doctor on the same day.
2. Modifier 77 if the same service is performed by Different doctors on the same day.
 If we have billed with modifiers and still claim denied for duplicate we will call to Insurance and
ask the representative to reprocess the claim.

6-GLOBAL (CO97)

It includes all the expenses of surgery, pre and post evaluation and management service under global
period:

In this denial, we will call to insurance and ask the following question to rep.

 Denial Date and Claim Number.

 We will ask what is Date of Surgery is.
 What is the global period?

1st Condition

If DOS falls under the global period, we will send the claim for coding review.

2nd Condition

If DOS falls after the global period.

 We will ask the representative to reprocess the claim.

 We will take a turnaround time and call Reference.

The modifier used in this denials are

1. 24 for Unrelated Evaluation and Management Service.

This modifier is used when patient come for Evaluation and Management Service under global
period which is not related to surgery.
7- The time limit for filing has expired (CO29)

Insurance will deny the claim with Denial code CO 29 – The time limit for filing has expired,
whenever the claims submitted after the time frame.

 We will call to Insurance.

 We will take Denial Date and Claim Number.
 When did they received the claim?
 What is their Timely Filing Limit?

1st Condition

If Insurance Received Claim under Timely Filing Limit.

 WE will ask Representative to reprocess the claim.

2nd Condition

If insurance received claim after Timely Filing Limit.

 We will check our billing software when did we filled the claim.
If we filled claim after Timely Filing Limit.
 We will write-off the claim.
If we filled claim under Timely Filling Limit.
 We will take appeal Limit and appeal address.
 Call ref#

Action

We will appeal with timely filing Limit Proof.(i.e. Eob and Clearing House Screenshot)

8. No Authorization (CO197)

For every expensive treatment Doctor need to take prior authorization from insurance company
and that authorization number, need to be billed on CMS 1500 form in BOX#23.

We will check our billing software whether we have authorization number available or not.

1st Condition

 If we found authorization number available in our system.

 We will call to insurance provide authorization number to representative and ask to send
claim for reprocess.
 We will take turnaround time & Call Reference Number.
2nd Condition

If we don’t have authorization number available in our billing software.

 We will verify place of Service (POS)

POS: Location where service was provided.

If place of service is 23 (Which is for emergency)

 We don’t require authorization number in emergency, so we will ask representative to send

the claim for reprocess.

If place of service is 21 (Which is for In-Hospital patient)

 We will ask representative to send the claim for reprocess with authorization number
available with hospital claim.

If they don’t have hospital claim or authorization number not available on hospital claim.

We will try to take authorization number from retro authorization department.

 If we get authorization from retro authorization Dept. we will ask representative to send
claim for reprocess. If we don’t get authorization then we will work as per client protocol.

9. Maximum benefit met/reached (PR119)

There can be two scenarios, it can be in term of dollar value and number of services.

 We will call to insurance;

 We will ask
 We will take denial date and claim number.
 What is the maximum benefit limit? Is it in term of service or in amount?
 If it is exceeded in term of amount or service. We will bill the claim to any other active
insurance or patient. If it is not exceeded we will ask rep to send claim back for reprocess.

10. Claim Not on File

This means claim is not received by insurance company.

We will verify

 Mailing address and Payer ID and Fax# No

 Effective and termination date of policy.
 Whether policy is primary or secondary on date of service.
 Filling Limit of Insurance.

Action:
If mailing address or payer id is incorrect we will correct it and we will rebill claim to insurance.

If mailing address or payer id is correct we will look for clearing house rejection and resole it and
again rebill claim to insurance.

11. Capitation (CO 24)

In This Method Healthcare Provider gets fixed payment from the insurance company, it is on per
member per month basis.

 The ratio in which capitation amount is paid is per member per month.
 Medicare and Medicaid deny claim for capitation as Doctor is capitated, so in this Scenario
we will bill Claim to Medicare HMO or Medicaid HMO.

12. Claim is paid

Claim is paid means claim has been processed by Insurance Company. However, the payment is
not posted in system. So we need to verify

 Claim Processed Date and Claim Number?

 What is allowed amount, paid amount and patient responsibility?
 What is mode of payment? Like EFT or Check. If it is EFT we will conform EFT Number and
EFT date and in case of check we will verify check number and check date. We will verify
payment address. If it is wrong then we will ask the representative to stop the payment and
reissue the check on correct address.