Denial Action Training

Welcome to All
 1. Non covered charges (Reason Code - 96)
Non covered charges denials are
received in 4 scenarios
1. DX non covered under
insurance guidelines
2. CPT non covered under the
insurance guidelines
3. CPT/DX non covered under
patient plan
4. DX/CPT non covered under
provider Contract
Action
First move to calling and verify correct reason.
1. If DX/CPT non covered under the insurance
guidelines. Verify any other insurance covers this
service or not (Example 1 : Mental health service
covered under separate insurance ) (Example 2:
Preventive visit codes like 99396, 99386 non
covered under medicare, so for this type of
scenario, we need to verify with Dr. office and
change to Well-Women Exam code G0439,
G0438, G0402 or need to bill E/M visit)
2. If DX/CPT non covered under patient plan,
inform Dr. office or bill the patient (based
on protocol)
3. If DX/CPT non covered under provider
contract, inform Dr. office.
Note: In these scenarios ticket should not be
moved to coding as the coder will not know the
patient plans
 2. Out of network or credential issue (Reason code 242)

Action.
First verify claim processed as in or out
network. Verify claim submitted with Individual Tax ID/NPI
or Group Tax ID/NPI (BOX 24J)
Please verify below mentioned step and
identify claim processed as in or out of 1. If Individual NPI/Group NPI, move to calling
network and verify if the provider was not credentialed
with the insurance, not credentialed in that
(I) Suppose patient has out of network particular plan or credentialing recently termed.
benefit, claim processed as out of network
deductible and EOB mentions as full billed 2. Suppose Group NPI is in-network, need to
amount is patient responsibility. check individual NPI attached with group NPI or
not.
(II) If patient already met out of network
deductible, claim processed as paid and 3. Finally confirm the credential information and
balance amount mentioned as patient inform to account manager.
responsibility.
4. If we already have a protocol for the same
(III) If patient does not have out of network scenario, need to follow the protocol.
benefit, claim denied as provider is not
credentialed (Reason code 242)
3. Medically not necessary. (Reason Code – 50)
Verify this claim was denied
based on LCD/NCD. If LCD and
NCD# is found in EOB, need to
clarify with coder with
LCD/NCD#
LCD means “Local Coverage
determination”
NCD means “National
Coverage determination”
For example:
1. Claim billed with CPT 90853 with DX
F10.10 and denied based on LCD# L34616,
need to verify the below mentioned link and
check this combination is correct or not.
https://www.cms.gov/medicare-coverage-
database/overview-and-quick-search.aspx
2. If we do not find the LCD/NCD# in
EOB, we need to move to calling and verify
the LCD/NCD#. If rep says this service is
not medically necessary for this patient, we
need to appeal with medical record to prove
this service is required for this patient. If we
again receive the same denial, then need to
inform Dr. office.
4. Maximum Benefit met (Reason Code - 119)

Three reasons to receive this denial:

1. Maximum allowed amount paid by insurance (Example : Per
patient plan $2400 allowed per year and this amount met before
submit the claim.)
2. Maximum allowed units met (Example 1: Some CPT's are
allowed only one unit per day but if we submit more than one unit,
we will receive this denial. Example 2: per year CPT 80305
allowed 8 units, if all the 8 units are exhausted before the current
ticket's DOS, then we will receive this type of denial.)
3. Maximum allowed CPT's met. (Example. Well Women Exam
and preventive visits can be billed only once in a year. If we have
already billed this service in that year, then we will receive this
denial)
5. Primary paid more than secondary allowed
amount (Reason Code – 23)
1. First check the secondary allowed amount. If we do not
have the ERA/EOB, move to calling and verify the
secondary allowed amount.
2. Again verify primary paid amount is same or more than
secondary allowed amount.
Example : Secondary allowed amount is $35.56 but
primary paid $45.00, in this case the balance should be
adjusted and the amount should not be billed to the patient
(Medicaid, Medicaid HMO and Commercial insurance)
6. Need authorization (Reason code 197)
1. First verify service requires authorization or referral authorization
2. If need authorization for this service, verify if previous claims billed with
same CPT. If yes, verify if any payment is received or not.
3. Also verify in patient record (Practice Fusion or patient attachment) any
approved authorization information is attached or not.
4. If website is available, verify any Auth# is generated for this DOS or not.
5. If the above mentioned informations are not available, need to move to
calling and verify whether this claim processed as INN or OON. If in-
network, need to check why this claim requires authorization?
6. Also confirm through call, any hospital claim already received with any
Auth# or not.
7. Also confirm retro Auth is possible or not. If possible, inform Dr. office.
If not possible, try to appeal with medical record. If we again received
same denial, inform Dr. office.
 7. Timely filling exceeded (Reason code - 29)

1. First check with charges/super bill received date and

submission date
2. Check the timely filing limit period.
3. If we have submitted the claim within the time limit, check with
insurance rep claim received date.
4. Once we have confirmed, the claim is submitted after the TFL,
inform account manager and take further action based on the
advice of the account manager.
5. If claim submitted within TFL or we have proof available that we
have done the first submission within the TFL period, need to
appeal with proof of TFL.
 8. Past Appealing Limit

1. First find the appealing limit period.

2. Verify the claim denied date and check we are within the time
limit to appeal in reference to the appealing limit period. Also move
to calling and get appeal receive date.
3. If possible to file second level appeal, need to appeal once
again.
4. If not possible, need to adjust based on protocol
 9. Inclusive or Mutually exclusive
(Reason code 97)
1. First identify inclusive with which CPT. (Need to verify CCI
edit Correct Coding Initiative)
2. If inclusive with any other CPT. Need to submit with
modifier 25 (E/M visit) or 59 (other service)
3. If cannot identify inclusive CPT, move to calling and verify
the inclusive CPT
4. If cannot identify which modifier to use, move to coder and
get the modifier.
5. If not possible to use any other modifier, move to Dr. office
for clarification.
 10. Global or Bundled

1. First identify the bundled CPT based on Global days.

2. If bundled with any other CPT, need to submit with
modifier 24 (E/M visit) or 79 (other service)
3. If cannot identify bundled CPT, move to calling and get the
bundled CPT
4. If cannot identify which modifier to use, move to coder and
get the modifier.
5. If not possible to use any other modifier, move to Dr. office
for clarification.
 11. Incorrect Place of Service

1. Verify billed CPT/POS is valid or not.

2. If cannot identify move to calling
3. Once calling is done and call notes are updated in
software, need to move to Dr. office to change the POS
4. If cannot identify which POS needs to be used based on
call notes, need to move to coder to get the valid POS.
Once we receive the coder reply, need to move to Dr. office
for change of POS
12. Missing or invalid or incomplete CPT code
1. Verify super coder website that billed CPT is correct or not.
2. If we identify that the billed CPT is already termed, then
need to move to coding to verify any alternate CPT is
available or not.
3. If cannot identify, move to calling.
4. Once receive the call notes, need to take action based on
call notes.
Example 1 – Suppose patient was new patient but we
billed established code or vice versa
Example 2 – Medicare covers well women exam code
G0438, G0439 & G0402 but we billed preventive code
99381 to 99397
Example 3 – Medicare covers admin CPT code starting
with G but we billed 9 series code
13. Missing or invalid or incomplete Modifier

1. First check claim billed with modifier or not. If not, verify

CCI edit and check whether modifier is required for this
service or not; if cannot identify, move to call and verify
whether modifier is required or not.
2. If already billed with a modifier, move to coder and verify
the modifier appended is correct or not.
3. If coder advises to use any other modifier, need to change
the modifier and submit corrected claim.
14. Patient cannot be identified as our insured
(Reason code 31, N30)
1. Verify patient eligibility through website and confirm claim
billed with correct patient first, last name and DOB. Also
confirm patient is subscriber or dependent. If dependent,
policy has coverage for dependent or not.
2. If Medicaid patient, need to confirm patient's plan is SLMB
or QMB. SLMB & QMB plans only pay Medicare premium.
So need to confirm with Dr. office to bill patient or adjust the
balance amount.
3. If insurance card copy is available, need to verify patient
name is correct or not.
15. Missing or invalid or incomplete Diagnosis
code
1. If claim rejected as DX invalid, need to check any non billable
DX billed in this claim or not.
Need to verify non billable code in below mentioned
website:
https://www.icd10data.com/
2. If denied as DX invalid, need to move to calling and verify which
DX is invalid.
3. Once we confirm the invalid DX, move to coder and get valid
DX
4. If coder suggested a new DX other than the billed DX, Place the
claim in Dr. Office to HOLD to get the approval to bill the DX
 16. Patient enrolled in Hospice

1. Most of the claims need to be billed Medicare with GW

modifier. Suppose initial claim filed to Medicare HMO
insurance, we should add GW modifier and submit the
claim to Medicare, not to Medicare HMO insurance.
2. For some specialists' claim (radiology/ pulmonary/ GI/
neurology), need to verify with coder whether this service is
related to terminal illness or not.
 17. Duplicate Claim/Service

1. Verify whether we have billed a claim for the same DOS

with same CPT and same provider.
2. If already billed need to adjust.
3. If not billed, need to move calling and verify with insurance
whether they have received any other claim from any other
provider for this DOS.
18. No claim on file or Claim not on file

1. Need to verify initial claim submit with correct payer id or

not.
2. Also verify initial claim accepted or rejected. If rejected,
need to work rejection.
3. If website is available for that insurance, need to check
claim status online.
4. If we do not find any claim, need to refile with correct
payer id. If fax# is available, need to fax the claim.
5. But, it is desired to be submitted as electronic claim for our
records, If the claim denied as TFL we can appeal the
claim using the Acceptance report and transmit log. But in
case we file the claim as paper submission or fax, we don't
have proof to appeal
19. No claim on file or Claim not on file

1. Need to verify initial claim submit with correct payer id or

not.
2. Also verify initial claim accepted or rejected. If rejected,
need to work rejection.
3. If website is available for that insurance, need to check
claim status online.
4. If we do not find any claim, need to refile with correct
payer id. If fax# is available, need to fax the claim.
5. But, it is desired to be submitted as electronic claim for our
records, If the claim denied as TFL we can appeal the
claim using the Acceptance report and transmit log. But in
case we file the claim as paper submission or fax, we don't
have proof to appeal
20. Member not eligible at the time of service,
Member coverage terminated or Policy Termed
1. If website available, need to verify the eligibility details in
web.
2. If website not available, move to calling and verify the
eligibility details
3. Once confirmed that the policy not active, need to verify
patient documents or practice fusion, any other active
policy is available or not. If not, need to inform Dr. office for
valid insurance or bill patient based on protocol
 21. COB (Co-ordination of benefit)

1. Need to confirm claim denied as need primary EOB or patient

needs to update COB
2. If need primary EOB, find primary insurance information through
web or calling and file to primary insurance. If do not find primary
details, need to inform Dr. office.
3. If already claim submitted to primary insurance, need to refile with
primary EOB through fax or mail.
4. If claim denied as patient need to update COB, inform Dr. office to
inform patient to update COB or bill patient (if protocol is there bill
patient directly).
 22. Member enrolled in HMO/MCO

1. Need to verify patient eligibility in web and find the HMO

insurance and resubmit the claim to HMO insurance
2. If do not find in web, move to calling and get the HMO
details
3. Once we got the valid HMO/MCO insurance information,
need to add the insurance in NueMD and refile the
claim. Also need to check whether any other
claim denied for the same reason for this patient
23. Lack of information which is needed for
adjudication
1. Move to calling and identify which information is needed
like Medical record, itemized bill, invoice bill, etc.
2. If claim denied for medical record, need to appeal with
medical record. If we do not find medical record in PF or
attachments, need to inform Dr. office and get the medical
record. Once medical records is received, need to appeal.
3. If denied for itemized bill, need to resubmit the claim form
4. if denied as need invoice bill, inform Dr. office and get the
invoice bill and appeal.