Insurance denial and appeal of denied claim?

 Insurance denial follow up and denial Management is the more important process in Medical billing which brings the regular money flow. As per one online poll almost 50% denied claims have not been resubmitted. So working on denial claim is very important.

So we need find the good strategy to work on the insurance denial. For that we need to understand the denial reason clearly and we should know the how to work on the denial.

List of insurance denial.

This list includes almost all major insurance denial such as Medicare, Medicaid, Aetna, Cigna, UHC, BCBS, Humana, Tricare, Champava,Medical and polk, universal healthcare and lot more.

Here I have given list of insurance which are very familiar and what will be the required actions for that denial.

Not covered when performed during the same session/date as a previously processed service for the patient. M80

A. Need to check in the system whether the same type of service was billed previously for the same DOS

B. Need to confirm any global period was applicable for this particular service.

C. If both criteria is not applicable, Call Insurance and discuss the denial status in detail and send back the claim for review if it was incorrectly denied.

Expenses incurred after the coverage terminated. 27

A. Check with Insurance for any other active Insurance coverage details. Sometimes, the pt coverage is active with New Mem Id# under same Plan. If it's the case, then update the New Mem Id# and refile the claim.

B. Check whether new Pt card copy was received/scanned in the system. If it's available then file the claim to

New Insurance after checking the eligibility details.

C. Call patient and check for active coverage details or else bill patient.

Your plan does not cover this visit, consultation, E&M or associated expenses. 8S

A. Call Insurance and confirm the Office visits/Consultation are not covered under patent's plan.

B. Call patient and check any other medical coverage is available or else bill patient.

Maximum preventative has been satisfied. R176

A. Check the total dollar amount available for physical examination codes per calendar year.

B. Call Insurance and chk whether pt met the whole amt.

C. If the amt was not met in full, send back the clm for review.

D. If the amt was met in full, bill pt for the balance amt.

No coverage for out of network providers. MU1

A. Check the old claims for the patient whether it was processed previously by this carrier.

B. Bill patient for the balance.

Other Insurance is Primary. M8

A. Call Insurance/Verify online to confirm whether the other Insurance is primary and also get the effective date.

B. If the Dos falls within the effective date, update/change the other Insurance as Primary and file the claim.

Maximum benefits reached. 01

A. Check the total dollar amount for the visits per calendar year and how much the pt met so far.
B. If amount was met in full, bill patient for the balance.
C. If amount was not met in full, ask to send the clm for review.

Claim denied for COB Info 16

A. After receiving this denial, call Insurance and check the COB info was updated. If it's updated, inquire about the current status.

B. If the COB info was not updated, Call patient and inform to update the COB info with Insurance.

Non Covered charges - Coverage only for Medicare Part A Benefits 96

A. Check with Medicare card copy/Insurance and confirm medical benefits was not available for the patient.

B. If it's not available, check for any other active coverage or else bill patient.

Your contract excludes this procedure or condition as a covered benefit. R048

A. Check/Consult with the coding dept., whether the submitted diagnosis code was compatible with the patient condition.

B. If it's not compatible, get any other alternate & related diagnosis code from the coding dept and refile the claim.

D55 - Timely limit for filing has expired.

Appealed the claim with clearing house acceptance report.

D28 - Aetna is not responsible for these charges. if there is no valid referral the member is responsible.

Get the referral from PCP and file the claim.

D62 - Claims are denied because procedure was not re certified.

Claim refiled with the auth# and got paid.

DMC - There is insufficient information to determine if other health coverage exists. An
inquiry was sent to the member.

Patient has to update the COB information to Aetna.

1 - Our records indicate that the member’s coverage terminated before you provided this services. The member is responsible for this charge(s).

Secondary balance billed to patient.

D82 - The patient’s medical history information has not been received for pre-existing determination.

If information required from provider then Refile with medical notes and received payments.

DPC - Member must contact the customer service area to select a primary care physician.

Sent for patient calling and requested him to update his PCP. After updated the PCP details got payment.

D30 - Charge is denied. Service/procedure is considered incidental/inclusive to the primary procedure or OV/Hosp consult fee

Added modifier and refiled the corrected claim.

N174 - This is not a covered service/procedure/ equipment/bed, however patient liability is limited to amounts shown in the adjustments under group PR.

Bill patient or take W O.

D16 - These charges are the result of an Auto Accident. Please bill the appropriate Auto insurance carrier.

Sent for patient calling and got the auto insurance information after that claim filed to the concerned insurance.

Some insurance denial required appeal process which we need to submit the appeal letter along with HCFA. This can be either sent by fax or by Mail.

Appeal process generally two or third level. The good way is appeal the claim after you talking to insurance representative and follow his guidelines.

Here is the some sample appeal letter for denied claims.

Appeal sample letter
Insurance denial appeal letter
Apeal letter for denied claims UHC

Finally insurance denial and Denial management is more important process and difficult process unless until we have the regular follow up,

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