Top ten Denials 1. Duplicates
2. Claim Not Covered by This Payer/Contractor
3. Missing/Incomplete Information on Where Services Furnished
4. Beneficiary Eligibility
5. Medical Necessity
6. Bundled Services
7. Non-Covered
8. Medicare Secondary Payer (MSP)
9. Provider Eligibility
10. Clinical Laboratory Improvement Amendments (CLIA)
1. Duplicates.
MRA reason code CO-18: Duplicate claim/service denials are associated with
identical services billed more than once per day.
· Remark message M86: Service denied because payment already made for same/similar procedure within the set time frame.
· Remark message N20: Service not payable with other services rendered on the same day.
Resolution
In order to reduce unnecessary duplicate claim filings, providers are encouraged to adopt the following processes:
— Has Medicare had enough time to process the claim? Providers should allow 30 days from the date a claim was received to process the claim for payment. If the provider is not enrolled in Electronic Funds Transfer (EFT), an additional 7–10 days should be allowed for mail time. Although electronic claims may be processed within 14 days, it could take as long as 30 days.
— To check the status of a claim, providers should call the Interactive Voice
Response (IVR). The IVR will not recognize a claim until it reaches a specific point in the processing system. This could take up to three business days from the date of transmittal for electronic claims and 14 business days from the date of receipt for paper claims.
— Special attention must be paid to zero-pay RAs in order to determine if the claim should be resubmitted. Often zero-pay is due to the allowed amount being applied to the patient’s deductible and resubmitting the claim will result in a duplicate denial message.
— If the same procedures are performed multiple times on the same day, the provider should refer to specific claims filing guidelines for multiple servicing and/or use the appropriate modifiers.
·–Providers should not repeat filings on claims with multiple detail lines. (Example: The original claim is reported with multiple services. One detail line is paid and the others fail to pay for various reasons (claim is split for processing). Instead of removing the paid service line and refilling only those services that denied/rejected, all original services are billed again.)
— Providers are encouraged to work with software vendors or billing services when a specific claim detail line cannot be individually filed and eliminate those services that have previously processed correctly. Providers should resubmit only those services that deny/reject and not resubmit services previously paid.
