Claim denial codes and actions

Claim Not in System


The claim may be refiled (fax / mail) after verifying the claims mailing address, filing time limit, processing time and additional documents to be attached.

Claim Denied for Pre-existing Condition


The Patient needs to be billed for the service rendered for pre-existing condition

Doctor Not Contracted


The Provider’s contract details are obtained and forwarded to the client

for an adjustment to be taken.

Procedure Not Payable


The details of the procedure are obtained and forwarded to the client, to be adjusted.
Provider Issue
The information required from the provider to process the claim is obtained and forwarded to the client for further action to be taken.

Claims paid and Off-set against another


The details of the invoice against which the claim has been offset along with the payment details are obtained and forwarded to the client.

Claims Paid but not posted


The Payment details like Check #, Date, Pay to Address and encashment are obtained and forwarded to the client for further action to be taken.

Non-Contractual Adjustment


The Denial Reason and Amount to be adjusted are forwarded to the client.

Authorization Required


If the Client provides the Authorization Number, further follow-up is made. The client takes an adjustment when authorization is not available.

Referral Required


If the Client provides the Referral Number, further follow-up is made. The client takes an adjustment when referral is not available.

Claims paid to wrong address


The Payment Details and the address to which the check was paid are forwarded to the client. The correct address may be updated or W-9 forms may be sent.

EOB / Remittance Advice Required


The details of the EOB / RA required are forwarded to the client and when the client provides the same, further follow up is made.

Capitation Payment


The Payment details are obtained and reported to client to be adjusted.

Claims in Process


When insurance companies state that the claim is in process we acquire details regarding the exact number of days after which the claim will be fully processed, contact person & how much will be paid.

Check In Mail


When the insurance company had already paid the claim we get the payment details along with the date of payment. If the payment does not reach the client within one month of the date of calling we do a follow up with the insurance company to trace the payment.

Claim pending by Insurance


When Insurance keeps the claim pending for want of Surgeons bill, Hospital Bill & Patient Information, a follow up is done with the insurance after the same is received from the client.

Links are simillar denials and solutions

http://billingatchennai.blogspot.com/2009/02/medicare-remittance-review-part-4.html

http://billingatchennai.blogspot.com/2009/02/medicare-remittance-advice-part-3.html

http://billingatchennai.blogspot.com/2009/01/medicare-remittance-advice-and.html

http://billingatchennai.blogspot.com/2008/10/denials-and-action-lacks-of-information.html

http://billingatchennai.blogspot.com/2008/09/medicare-denial-and-action-enrolled-in.html

http://billingatchennai.blogspot.com/2009/06/ar-person-role-and-responsibility.html

http://billingatchennai.blogspot.com/2009/06/denial-and-actions-co-b16.html

1 comment:

Shani said...

I am new in this field and want to know few things related to denial codes and what should be the action.

our company provide services to US providers related to coding, billing, posting and collection.

i am a part of posting, sometime we recieve Partly paid and REFUSED entries (which is unpaid) and the reason code with that EOB

now i have the confusion what should be the action on that Reason code

for example:
the most used reason codes for Medicare Posting.

B15
B18
N-23
50
18

Now we have Coding, billing and collection dept. and i need to report them according to reason , if the reason is something which is related to billing department, i should report them , if there is some mistake with coding , i need to report coding dept. , if there is some collection left from patient or ins. co. then i need to report collection dept.

Kindly help me in understanding reason codes and where to rpeort and what should be the action.

EXAMPLE:

B7 - This provider was not certified/eligible to be paid for this procedure/service on this date of service.

from my understanding , i would report to billing dept. and ask them to verify date of service.

hope i would get some good reply..
--
N23 - Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provision

B15- This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

B-18 - This procedure code and modifier were invalid on the date of service

N23 - Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provision

50 - These are non-covered services because this is not deemed a `medical necessity\' by the payer.

18 - Duplicate claim/service

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