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  • Claim Denied As Inclusive

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    Uavesh Ansari
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    A claim was denied by an insurance company as the billed CPT code was inclusive or bundled with the primary CPT code and not payable. The document provides steps to take in CareCloud depending on the claim scenario: 1) if billed without a modifier, obtain the primary procedure; 2) if billed with a modifier but no records for appeal, task the practice; 3) if incorrectly denied with records, task appealing via fax/mail. Questions to ask the insurance company and actions to take if appealing are also outlined.

    Original Description:

    How to follow up on denials

    Original Title

    Claim denied as inclusive

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    A claim was denied by an insurance company as the billed CPT code was inclusive or bundled with the primary CPT code and not payable. The document provides steps to take in CareCloud depending on the claim scenario: 1) if billed without a modifier, obtain the primary procedure; 2) if billed with a modifier but no records for appeal, task the practice; 3) if incorrectly denied with records, task appealing via fax/mail. Questions to ask the insurance company and actions to take if appealing are also outlined.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    122 views3 pages

    Claim Denied As Inclusive

    Uploaded by

    Uavesh Ansari
    A claim was denied by an insurance company as the billed CPT code was inclusive or bundled with the primary CPT code and not payable. The document provides steps to take in CareCloud depending on the claim scenario: 1) if billed without a modifier, obtain the primary procedure; 2) if billed with a modifier but no records for appeal, task the practice; 3) if incorrectly denied with records, task appealing via fax/mail. Questions to ask the insurance company and actions to take if appealing are also outlined.

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    © All Rights Reserved
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    of 3

    DENIAL PATHWAY

    Claim denied as inclusive or bundled

    DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
    document may not be reproduced or reviewed by any person who is not an employee of Pacific.
    Claim denied as inclusive or bundled

    Meaning:

    Patient walked into provider’s office and got treatment and claim billed to insurance company but insurance
    representative stating that CPT code which we billed inclusive with the primary CPT code and this CPT is not
    payable.

    Steps in CareCloud:

    1. To be entered by Vishal

    Question To Be asked On Call-

    1. May I know the date on which this claim denied, claim#?


    2. Can you please tell me to which major procedure the claim has been bundled/ incidental/ inclusive to?
    3. Is it possible for me to appeal this claim?
    4. May I fax this claim with medical notes to your attention or do I have to mail it to you?
    5. Could you please fax/mail a copy of the explanation of benefits?
    6. May I have corrected claim limit and address /Appeal limit and address?

    Claim scenario 1:

    If claim was billed without modifier, then get the primary procedure to which it is inclusive.

    Action:

    1. Need to obtain the primary procedure to which it is inclusive


    2. Create a task to practice for review

    .
    Action Description Action Taken Code Care Cloud Follow-up
    Action Days

    Ask practice to review


    Pended: Coding Issues  Create a task NA
    CPT/DX/Mod changes

    DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
    document may not be reproduced or reviewed by any person who is not an employee of Pacific.
    Claim scenario 2:

    If claim was billed with modifier but was denied and we do not have medical records to file an appeal

    Action:

    1. Create a task to practice for the same

    .
    Action Description Action Taken Code Care Cloud Follow-up
    Action Days

    Ask practice to review


    Pended: Coding Issues  Create a task NA
    CPT/DX/Mod changes

    Claim scenario 3:

    If claim was billed with modifier but was denied incorrectly and we have medical records to file an appeal

    Action:

    1. Create a task to practice for the same

    .
    Action Description Action Taken Code Care Cloud Follow-up
    Action Days
    If denial incorrect,
    appealing via FAX or Pended: Appeal Create a Task NA
    sending MR

    If denial incorrect and


    Pended: Appeal Create a task NA
    appealing denial (via Mail)

    DISCLAIMER: The content, concepts, approaches and methods proposed in this document are confidential. This
    document may not be reproduced or reviewed by any person who is not an employee of Pacific.

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