Denial Code CO 22

Denial Code CO 22 – This care may be covered by another payer as per coordination of Benefits.

When an insurance company denies a claim with denial code CO 22, it means that the services billed should be paid by another primary payer according to the coordination of benefits (COB) guidelines. In this scenario, the insurance company is not the primary payer as per COB rules, and therefore, the claim should be submitted to the primary insurance first for reimbursement. COB is a process used by insurance companies to determine the order of payment when a patient is covered by more than one insurance plan. The primary insurance is typically responsible for paying claims first, and the secondary insurance covers any remaining costs up to the policy limits.

When updating insurance details with a healthcare provider at the time of service, the patient plays a crucial role in ensuring a smooth billing process and avoiding denials such as the CO 22 code. It is essential for patients to accurately inform the provider about the order of their insurances – primary, secondary, tertiary, and so on. By clearly stating which insurance should be billed first, second, and so forth, patients can help the provider navigate the complex world of insurance billing more efficiently.

One key concept to emphasize is the importance of proper communication between the patient and provider regarding insurance coverage. Patients should thoroughly review their insurance policies and understand the coordination of benefits rules to prioritize the order of payment. This not only helps in avoiding denials but also streamlines the billing process and reduces the risk of surprise bills or unexpected expenses.

In the realm of medical billing, it is crucial for the Billing team to diligently fulfil its responsibility of verifying patient eligibility and ensuring that claims are submitted to the correct payer for reimbursement. By proactively confirming eligibility, the team can prevent claim denials and delays in payment processing. This process involves verifying patient insurance coverage, understanding benefit structures, and confirming that services rendered are covered under the patient’s plan.

What is Coordination of Benefits?

Coordination of Benefits (COB) is a critical component of the healthcare payment system, serving to determine the primary, secondary, and tertiary payers for patients with multiple active insurance coverages. This essential rule is in place to prevent duplicate payments to providers for services rendered and to ensure that payments are made by the correct payer in sequence – primary, then secondary, and so on.

Denial Code CO 22 resolution:

In this scenario, we may come across three possibilities:

1. When patient is having other active primary insurance for the services rendered at the time of service, but the claims are submitted to other insurance.

When a claim is denied with denial code CO 22, healthcare providers should first verify the patient’s eligibility to identify the primary, secondary, and tertiary insurance coverage. Once the active primary payer is determined, the claim should be updated and billed to the primary insurance. After the primary insurer processes the claim and makes payment, any remaining balance should be billed to the secondary payer along with the primary Explanation of Benefits (EOB) for reimbursement.

• Patient is having only one active insurance, but insurance still denied with CO 22.

In the scenario where a claim is denied with denial code CO 22 due to incorrect Coordination of Benefits (COB) information despite the patient having only one insurance for the service rendered, it is crucial to educate the patient on the necessary steps to rectify the situation. In such cases, it is imperative for the patient to proactively engage with their insurance provider to update and correct the COB information, ensuring that the claim can be processed and reimbursed accordingly.

• Patient is having more than one insurance, but payers have confusion as which is primary and then secondary.

In cases where a patient has more than one insurance, it is essential to determine which insurance will serve as the primary and which as the secondary coverage. This process, known as Coordination of Benefits (COB), plays a crucial role in ensuring proper reimbursement for medical services rendered. Ambiguity or conflicting information regarding primary and secondary insurance coverage can lead to delays in processing claims and reimbursement issues.

Healthcare providers must proactively engage with the patient to update and verify their COB information with the insurance companies. This involves collecting accurate details of all insurance policies in place, including policy numbers, coverage start dates, and any other pertinent information. By maintaining up-to-date information, providers can facilitate smoother claims processing and reimbursement procedures.

Educating patients on the importance of updating their COB information with insurance companies is key. Patients should be informed about the implications of inaccurate or outdated insurance details, such as potential claim denials or delays in processing.

Questions need to be asked when you reach out representative:

• May I know the claim denied or pending date?
• May I know what information is required from patient?
• Have you sent a letter to patient?
• If yes, then ask how many letters were sent and when was the last letter sent to patient?
• Have you received any response from patient?
• If patient has responded with the required information, then request claim-rep to reprocess the claim

If patient has not responded, then request claim-representative to send one more letter to patient.

Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)