Denials Category

Coding Related Denials

Inclusive/Bundle (CO 97) Global (CO 97) Non-Medical Necessity (CO 97)

Eligibility Related Denials

Coverage Exhausted (PR26) Capitation Denial when received with Medicaid (CO24)

Covered By another Payer (CO22) Non Covered Services (CO96)

Maximum benefit met/Reached (PR119)

Other than Eligibility and Coding

No Referral (CO165) Authorization (CO97) TFL (CO29) Duplicate (CO18)

Lack of Information (CO16)

Credential Related Denials

NPI Invalid

Scnerio (This is not a denials)

Claim Not on File Claim Paid Claim Under Process

AR work on behalf of doctor. We make call to Insurance company to check status of claim.
We never make call to patient and we never receive call.
Denials Notes

1- 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 work as per client protocol.
 If service is not covered under patient plan we will bill the claim to any other active Insurance or
patient.

2-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 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.

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

The modifier used in inclusive denial:

1. 59-Distinct Procedure Service(Substitute:X(EPSU)

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

Note: Modifier 25 is used when two separate evaluation and management service performed on
same day separately.
3-GLOBAL (CO97)

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

Note: Global period is of two types for Major Surgery it is 90 days and for minor surgery it is 10 days.

 We will call to insurance and take Denial Date and Claim Number.
 We will ask what Date of Surgery is.
 What is the global period?

1st Condition

If DOS falls under the global period we will chech check DX code, if DX is same we will write off the claim.
If DX is different we will send claim to coding to append modifier.
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.

4. 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 activeinsurance or
patient. If it is not exceeded we will ask rep to send claim back for reprocess.

5. CO 24 – Charges are covered under a capitation agreement or managed care plan

If received capitation denial need to check capitation grid, to see if the particular provider is capitated with insurance, If
capitated need to call insurance and take date from which provider is capitated, Allowed Amount, Amount applied
towards capitation and is their any patient resposibility. We will bill the Patient resposibility to patient, and we will write
off the capitated amount.

Notes: If this denial from medicaid this means patient have medicaid HMO and need to bill
claim to Medicaid HMO.
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 active on the date of service

 We will call to insurance and ask the representative to reprocess the claim.

2nd Condition

If found the insurance not active on the date of service

 We will look for the other 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 found the same insurance is Primary than we will call to insurance and 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 Insurance.

If we found conflicts between two insurance than we will send a statement to the patient for COB
update.
3-DUPLICATE (CO-18)

If the same service is billed twice or the same service is performed twice and billed without modifier
insurance 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.

4- 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)
5. No Authorization (CO197)

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

1st Condition

 If we found authorization number available in our Billing Software.

 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.
 However some insurance want provider to take authorization number even in case of
emergency after the service is being performed. So authorization post service is taken from
retro authorization department.

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 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 retro authorization then we will take appeal limit and appeal address.
6. 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.

7. 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.