Denial Code CO 31 or PR31 – Patient Cannot be identified as our insured
When an insurance company is unable to identify the patient in a healthcare claim submitted by a provider for reimbursement, the claim will be denied with denial code CO 31 or PR31. This denial code signifies that the patient cannot be confirmed as an insured individual, hence, the claim cannot be processed for reimbursement. This situation often arises due to discrepancies in the patient’s insurance information provided by the healthcare provider or errors in the patient’s details leading to misidentification.
Causes for the denial code CO 31 or PR31?
There are several common reasons for receiving a denial with denial code CO 31 or PR31 code:
1. Name discrepancies: If there is a discrepancy in the patient’s name between what was submitted on the claim and what is on file with the insurance company, it can lead to the identification issue.
2. Incorrect Subscriber ID: Submitting an incorrect or outdated subscriber ID for the insurance policy can result in the insurance company being unable to link the patient to the correct policy.
3. Incorrect Date of Birth: Providing an incorrect date of birth for the patient can also lead to identification problems, as the insurance company relies on accurate patient information to process claims.
4. Claim billed to the wrong payer: If the claim was mistakenly billed to a different insurance company than the one covering the patient, it can cause confusion and result in a denial.
5. Incorrect claim mailing address: Submitting the claim to the wrong mailing address can cause delays in processing and lead to identification issues, especially if the claim does not reach the correct department within the insurance company.
Denial Co 31 or PR31 resolutions:
- The first step in the insurance claim process should always be to check the application for a copy of the patient’s insurance card. Once the insurance card copy is obtained, the next crucial step is to verify the patient’s eligibility and ensure that their policy is active for the date of service (DOS). If the patient’s policy is active, it is essential to update all patient and insurance details accurately before rebilling the claim with the correct information.
- If the insurance card copy is not found, the next step is to examine the previous date of service to determine if claims were submitted to the same payer or different payers. Additionally, it is important to verify if any payments have been received for the previous date of service.
- If a payment has been received from the same payer for the mentioned date of service, the next step is to locate the corresponding Explanation of Benefits (EOB) to obtain the correct patient details. The EOB contains vital information such as patient name, date of service, procedure codes, payment details, and any adjustments made by the insurance company. In the absence of the paid EOB, it is necessary to proactively reach out to the claims representative associated with the paid claim number.
- If previous Date of Service (DOS) is missing or unpaid, it is crucial to promptly engage with the claim representative department. A thorough search using the patient’s Name, date of birth, or social security number should be conducted to locate the relevant information.
- Once the patient is identified, the next critical step is to verify whether the claim has been received and processed.
- If the DOS is available, gather details such as the claim status, claim number, Cal reference number, and then proceed with the necessary actions to address the outstanding payment.
- When a representative is unable to locate the Date of Service (DOS) for a patient, it is imperative to ensure the accuracy of the patient’s information to facilitate proper billing procedures. Begin by obtaining the correct Patient Member ID, Name, and Date of Birth to accurately identify the individual. Verify the active status of the patient’s policy for the specific date of service in question to determine insurance coverage.
- If the insurance is active for the DOS, it is crucial to retrieve the patient’s effective and termination dates within their insurance policy. Understanding these dates is essential for successful claims processing and reimbursement. Additionally, gather information on the timely filing limit, which denotes the deadline by which a claim must be submitted to the insurance company to be considered for payment.
- Finally, obtain the claim mailing address where the completed claim form should be submitted. Ensuring the correct address is used is essential to guarantee that the claim reaches the appropriate department for processing in a timely manner. By following these steps meticulously, healthcare providers can streamline their billing processes, minimize claim rejections, and maintain efficient revenue cycle management
- In situations where all avenues for identifying a patient through insurance have been exhausted without success, it becomes imperative to directly reach out to the patient to obtain correct payer details
Note: When faced with denial code CO 31 or PR31, it is crucial to review all the dates of service in the patient account meticulously. When you find the correct patient and insurance details, it is crucial to conduct a thorough review of the patient’s account to determine if any previous claims were submitted with inaccurate information or if the insurance company had already issued a denial with denial code CO 31 or PR31. If either scenario is identified, it is imperative to promptly update the relevant patient and insurance details and resubmit the claims for reimbursement
Medical Billing Denials and actions – Top Denial codes Solutions (medicalbillingcycle.com)