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DENIAL MANAGEMENT

IN AND OUT OF
NETWORK
STEPHANIE THOMAS CPC, CANPC
OBJECTIVES

• Identify denial trends


• Work denials quickly and efficiently
• Determine whether appeal is necessary
• Feel confident in appeals processes
• Implement strategies to reduce payer denials
TYPES OF DENIALS

• Front end edits:


• Also called “Unbilled” “Code correct” “Pending with errors”

• Clearinghouse edits:
• Also called “exclusions” “clearinghouse rejected”

• Denials
• EOB denials, ERA reports
FRONT END DENIALS

1. Demographic info
2. Internal coverage dates (ex policy termed 8/31)
3. Authorization info
4. NDC and quantity
5. Referral, referring NPI
6. General coding guidelines
7. ICD10 verification
CLEARINGHOUSE DENIALS

• Coverage (more definitive)


• Subscriber info (DOB, address, ID #)
• Provider credentialing
• Referrals
• Authorizations
• ICD 10 errors (unspecified etc.)
• MSP (Medicare)
EOB DENIALS

• Coverage and COB


• Authorization and referrals
• Global period
• Medical Necessity
• Non covered benefits
• Medical Records needed
• Non Par OON
• Duplicate
• Claim lacks info
DENIAL EXAMPLES
• CO-96 Non covered charges
✓ Consult plan benefit documents/guidelines for information about restrictions for this service.
Check with payer if patient may be billed
• CO-18 Duplicate
✓ Confirm whether claim has been paid or previously denied. Work off initial processing
• PR-27 Coverage termed, CO-22 COB, PR-31 Patient cannot be identified, CO-24
covered under capitation
✓ Verify coverage with patient and payer
✓ Watch for replacement plans
COMMON DENIAL EXAMPLES CONT.

• CO-196 PA exceeded, CO-197 PA absent, CO-39 PA denied when requested, CO-15 PA


#missing or invalid
✓ Verify Pre authorization (CPT, ICD10, dates, etc.)

• CO-50 Non covered services, not “medically necessary”


✓ Review LCD, NCD guidelines, diagnosis codes, documentation

• CO-16 Claim/Service lack info which is needed for adjudication


✓ Look to remark codes for additional info. Contact payer for more info if needed
COMMON DENIAL EXAMPLES CONT.

• CO-29 Timely filing limit has expired


✓ Review submissions to verify if claim was sent timely. If not appeal with reasons for late
submission

• CO-252 An attachment/other documentation is required to adjudicate this claim/service


✓ Submit with documentation, in the future send upon first submission

• CO-234 Procedure not paid separately, CO-97 benefit included in another adjudicated
service
✓ Check NCCI edits and plan guidelines. Add modifier if appropriate
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