Health insurance claim denials

ADCB-Global Service previously paid

The procedure was covered as part of a previouslypaid procedure. The service is not payable as adistinct service.Use correct Modifier or take write off.

ADMD-Invalid Modifier Code Submitted

The modifier submitted is not appropriate for theprocedure. Please

resubmit a corrected claims withthe appropriate modifier.

Duplicate of a Previously Processed claim

As stated in the Ingenix® Coder’s Desk Reference forProcedures, modifier 76 can be used “to identify aprocedure or service that was repeated subsequent tothe original procedure or service” to avoid denial of aduplicate claim with identical Member/DOS/

D54 - Capitated Coverage

The service billed is covered under a capitationarrangement and will therefore not be paid.

Modifier 50 Invalid

Identifies an identical procedure performed bilaterallyduring a single operative session. Do not use when aprocedure code description already identifies theprocedure as being bilateral or where the organ isconsidered midline (ex. bladder, uterus).

Submit Primary EOB

Based on our records, the patient has primaryinsurance other than that managed by CMO. In thiscase, CMO will act as the secondary payor. CMOrequires the primary carrier's EOB to demonstrate ourfinancial obligation.

DGDI - Diagnosis invalid for gender

The diagnosis is not appropriate for the gender of themember. Correct the claim and resubmit to CMO.

Diagnosis Requires 4th/5th Digit

Certain ICD-9 codes have varying levels of specificity.CMS guidelines require that these diagnosis codesprovide a 4th or 5th digit to be considered for payment.

DIPC - Invalid ICD9 Procedure Code

The procedure code provided is not valid. Correct theclaim and resubmit to CMO.

DOP-Please submit operative report

Denied- Operative Report requested. Please printclaim on paper and submit with operative report forpayment consideration.

1 comment:

Kyra said...

For claiming your health insurance, you really need to provide an accurate information and process all the files that needed.

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