Denials and Actions

Denial Codes with actions
No Claim on file	Claim is in process
Claim Paid Status	PR 1 – Claim applied towards Deductible
Pre-existing information	PR 4 Denial Code
PR 11 Denial Code	PR 16 Denial Code
PR 18 Denial Code	PR 22 Denial Code
PR 23 Denial Code	PR 24 Denial Code
PR 27 Denial Code	PR 29 Denial Code
PR 31 Denial Code	PR 50 Denial Code
PR 96 Denial Code	PR 97 Denial Code
PR 119 Denial Code	PR 197 Denial Code
PR 226 Denial Code	PR B9 Denial Code

1

No Claim on file
1	Could you please check whether the patient is eligible for the DOS billed?
2	If patient is eligible for DOS	If patient is not eligible for the DOS
3	May I have the TFL (Timely Filing Limit) to submit the claim?	Check with rep, whether member is having any other insurance/policy details and whether those details available with them?
4	May I have the claims mailing address to submit the claim? (If its electronic get the correct payor ID)	If yes, Get the insurance name, policy ID# and Contact#	If no, check in the application and bill the claim to other active insurances
5	Bill the claim to correct claim mailing address or to the correct payor ID for reimbursement.		If no active insurances, then bill the patient to get active insurance details.
Note: Check the clearing house to see if the claim is rejected, if rejected then we need to take action as per the rejection from clearing house.
			Denials and Action List

2

Claim is in process
1	May I know the date when you received the claim?
2	Get the claim processing time?
3	If it is within 30 days	If it is more than 30 days
	Please allow some more time to process the claim if claim received within 30 days from the received date, Close the call with claim# and calreference #	Get the delay reason for processing the claim? Request rep to process the claim soon and end the call with claim# and Calref#.
		Denials and Action List

3

Claim Paid
1	May I know date the claim was processed and paid?
2	Get the allowed amount, Paid amount and patient responsibility (Copay/Deductible/Coinsurance)
3	Check the pay to address?
	If claim paid to Provider		If claim paid to patient
4	Is it paid through check number or EFT number?		Get the claim allowed amount, paid amount and patient responsibility from the rep. Finally in this scenario, we need to bill the claim to patient.
	If it is thru Check get the following details:	If it is thru EFT, then get the following details:
5	Get the Check number?	Get the EFT#
6	Is it a single check or bulk check?
7	If it is Bulk check, then get the bulk check amount?	May I know whether it is single amount for Bulk amount
8	May I know the check mailing address? If check mailing address is wrong then inform the rep that check mailing address is wrong and ask her to stop the payment and request them to resend check with correct mailing address
9	May I know the check cash date?	If it is Bulk amount, then get the bulk amount details
10	If no cash date and if it is more than 30 days, then request rep to do a check trace. (Note: When you have initiated a check trace, then we need to wait till the time given by rep and then follow up to find out where the check sent to.)
11	If it is more than 30 days, then request a copy of EOB to the pay to address or Fax number. Once EOB received send it to the posting team to post the claim.
			Denials and Action List

4

PR 1 – Claim processed towards Deductible
1	May I know what is the amount allowed for this claim?
2	What is the amount applied towards deductible?
3	Get the annual deductible amount for the patient?
4	Check if its in-network or out of network deductible?
5	Check if its Family or individual deductible?
6	Next step is to check how much deductible met so far by the patient as of this claim?
7	Request a copy of EOB, if the claim processed more than 30 days.
8	Once you have EOB, then check application to see if patient is having any active secondary payer for the DOS. If yes, then submit the claim along with primary EOB.
9	If no secondary payer, then bill deductible amount to patient.
	Denials and Action List

5

Claim Denied as Pre-existing Information
1	If representative says pre-existing information needed from patient
2	May I know the start and end date of the waiting period to cover the pre-existing condition?
3	Have you sent any letter sent to the patient requesting the pre-existing information
	If they have sent letter to patient	If letter not sent to patient
4	May I know how many letters were sent so far and when was the last letter sent?	Could you please send a letter to patient
5	Is there any response from the patient. If yes, then could you please send the claim back for reprocessing.
6	If last letter sent was more than 30 days, then request rep to send one more letter to patient.
7	Could you please send the claim back for reprocess
8	May I know the claim#
9	May I know the call ref#
Note: Do not bill the claim to secondary or consecutive payer as they are not going to reimburse the claim. We need to bill patient, if Date of service lies within the waiting period. If Date of service not lies between the waiting period, then request rep to reprocess the claim.
		Denials and Action List

6

PR 4 Denial Code – CPT code inconsistent with the modifier or a required modifier is missing
1	Check in application (Claims history) and see whether the denied CPT and modifier combination was paid for previous Date of service by the same payer.
2	If yes, Check the same with representative and send this claim back for reprocessing.
3	If no, get the corrected claim mailing address or Fax# and the timely filing limit to submit a corrected claim.
4	Also get the appealing address or fax# and appeal timely filing limit
5	Send the claim to coding team for a correct modifier. If they have corrected the claim with appropriate modifier, then update the correct modifier and send the claim to insurance company as corrected claim for reimbursement.
6	If coding team states the modifier and CPT code is appropriate but still insurance denied the claim, then we need to appeal the claim along with supporting documents.
	Denials and Action List

7

PR 11 Denial Code – DX code inconsistent with the CPT
1	If claim billed with multiple diagnosis code, then check with rep which diagnosis code is invalid
2	Check in application (Claims history) and see whether the denied CPT and diagnosis combination was paid for previous Date of service by the same payer.
3	If yes, Check the same with representative and send this claim back for reprocessing.
4	If no, get the corrected claim mailing address or Fax# and the timely filing limit to submit a corrected claim if required.
5	Also get the appealing address or fax# and appeal timely filing limit to appeal the claim if required.
6	Send the claim to coding team for a correct diagnosis code. If they have corrected the claim with appropriate diagnosis, then update the correct diagnosis and send the claim to insurance company as corrected claim for reimbursement.
7	If coding team states the diagnosis and CPT code is valid and appropriate, but still insurance denied the claim. Then we need to appeal the claim along with supporting documents.
	Denials and Action List

8

PR 16 Denial Code – Claim denied as Lack of information which is needed for adjudication
1	We receive this denial when insurance company cannot adjudicate the claim due to incorrect or incomplete details.
2	Whenever we receive the above denial, first step is to check exactly what information is lacking for adjudication. Either it can be checked with representative by reaching the insurance claims department or we need to check the remark codes associated with denial code CO 16.
3	Get the Corrected claim address or Fax#, time frame to submit the lacking information and also get appeal address and time frame to appeal the claim.
4	Submit the claim along with lacking information for reimbursement.
		Denials and Action List

9

PR 18 Denial Code – Claim denied as Duplicate Claim
1	If claim billed more than once to the insurance company, then we need to check for the original status of the claim. If original status of the claim is denied, then take necessary steps based on the reason for the denial. If original status is paid, then go by the paid status scenario.
2	If patient receives same service by the 2 different doctors and the other doctor claim processed and paid prior to your claim, then insurance will deny with denial code CO 18. In this case we need to send the claim back for reprocessing stating same service performed by 2 different doctors and get the processing time.
3	If rep disagreed to send the claim back for reprocessing, then get the appealing address and time frame to appeal the claim.
4	If same service performed more than once by the same doctor and claim billed without an appropriate modifier, then claim will be denied with CO 18 denial code. In this case we need to append 76 modifier or check with coding team for an appropriate modifier and send the claim as corrected claim along with supporting documents. Get the corrected claim mailing address and time frame to submit the corrected claim.
5	If same service performed bilaterally but claim billed without an appropriate modifier (RT & LT), then insurance will pay for one line item and other line item will be denied as duplicate. In this case we need to add appropriate modifier (RT & LT) and resubmit the claim as corrected claim. Get the corrected claim mailing address and time frame to submit the corrected claim.
	Denials and Action List

10

PR 22 Denial Code – Claim denied for COB information needed from the patient
1	If representative says COB information needed from patient
2	Have you sent any letter to patient requesting COB information?
	If yes	If no
3	If they have sent letter to patient	If letter not sent to patient
4	May I know how many letters were sent so far and when was the last letter sent?	Could you please send a letter to patient
5	Is there any response from the patient. If yes, then could you please send the claim back for reprocessing.
6	If last letter sent was more than 30 days, then request rep to send one more letter to patient.
7	Even after sending many letters if patient has not responded, then bill the patient.
Note: Check application to see if any recent date of service received a payment from the other insurances as a primary. If received, then check the eligibility for the DOS and bill the claim to those insurances for reimbursement.
		Denials and Action List

11

PR 23 Denial Code – Claim denied as Primary insurance paid more than Secondary insurance allowable amount
1	We get this denial from secondary or tertiary insurances. whenever you get this denial the very first step is to check primary insurance allowable and paid amount with the secondary insurance allowable amount. If primary paid is not more than secondary allowance, then secondary insurance denial CO 22 is invalid, call secondary insurance claims department and send the claim back for reprocessing.
2	If primary insurance paid more than secondary insurance allowable amount. If it is valid, then we need to write off the charges.
	Denials and Action List

12

PR 24 Denial Code – Claim denied as charges are covered under a capitation or managed care plan
1	When claim denied as Co 24 first check is this claim processed towards capitation or claim denied as services are covered under managed care plan?
	If the claim denied as services are covered under managed care plan, then follow the below steps:	If it is processed towards capitation follow the below steps:
2	First step is to check which managed care plan patient has and we need to update that managed care plan insurance and submit the claim for reimbursement.	Check with rep start and end date of capitation agreement
3	You can check the system to find the managed care insurance patient has or check Medicare eligibility or you check with representative for the managed care insurance details?	If the date of service billed doesn’t lie between the capitation start and end date, then we need to request rep to send the claim back for reprocessing. Get the processing time?
4	After obtaining managed care plan details, then final step is to check eligibility, update the insurance details in system and submit the claim to managed care insurance.	If the date of service billed lies between the start and end date of capitation agreement, then we need to get the below details: Insurance allowed amount, Capitation amount and patient responsibility. We need to adjust the capitation amount.
		Denials and Action List

13

PR 27 Denial Code – Expenses incurred after policy coverage terminated
1	May I know the Patient policy effective date and termination date?
2	If date of service billed lies between policy effective date and termination date, then request representative to send the claim back for reprocessing and get the claim processing time?
3	If date of service billed not lies between policy effective date and termination date, then check with rep for any other active policy available for the patient. If rep says active policy available, then get those details: May I have the policy ID? May I know the policy effective and termination date? Then update the active policy details for the DOS and submit the claim.
4	If no other active policy found with representative, then check in the application to see any other active insurance details available for the DOS. If found then make it as primary and bill the claim.
5	If no other active insurance found, then bill the patient.
		Denials and Action List

14

PR 29 Denial Code – Claim denied as Past Filing Limit
1	When you receive the above denial, first step is to check the timely filing limit to submit the claim for that insurance company.
2	Get the claim received date from the insurance company?
3	Next step is to verify whether the claim billed within the timely filing limit?
4	If it is within the timely filing limit, then request rep to send the claim back for reprocessing as claim submitted within the time frame.
5	If claim not filed within the time frame set by insurance, then we need to check whether we submitted the claim within time frame and whether we have any proof of time filing in the system. If available, then appeal the claim along with POTF. Get the appealing address or fax# and time frame to appeal the claim along with POTF.
6	If claim submitted after the time frame and there is no Proof of time filing, then we need to write off the claim.
		Denials and Action List

15

PR 31 Denial Code- Patient cannot be identified as our insured
1	Check with patient’s name, date of birth, first name, last name and SSN#
2	If representative unable to pull with the above data, then patient may not have policy with that insurance company.
3	Then, next step is to check in the application for other active insurances. If other active insurance found, then bill the claim to that active insurance for reimbursement.
4	If no active insurance details in application, then we need to bill the patient for valid insurance information.
	Denials and Action List

16

Denial Code PR 50 – Claim denied as non-covered service as this is not deemed medically necessity by the payer
1	When claim denied as above, the first step is to check the payment history in the system. If the same CPT and DX code billed and received a payment.
2	If we have received, we need to inform same with rep as previous date of service we received a payment with same procedure code and dx code. Please send the claim back for reprocessing. Get the processing time?
3	If we have not received, then get the corrected claim or fax# and also appeal address and time frame to appeal the claim.
4	We need to forward this claim to coding team to review the claim. If coding team corrects the claim, then send the claim as corrected claim.
5	If coding team states the claim billed is correct, then we need to appeal the claim along with medical records.
	Denials and Action List

17

Denial Code PR 96 – Non covered Charges
1	When representative states claim denied as non-covered charges, then ask rep under what criteria it is non-covered?
2	Next step is to check whether claim is non-covered as per patient plan or provider contract.
3	Check in application (Claims history) and see whether the same procedure and dx code was paid for previous Date of service by the same payer. If yes, request rep to send the claim back for reprocessing.
4	If no, then ask what is the reason for non-covered?
5	If rep says the dx code or CPT code billed is not covered. Then get Claim mailing address/Fax#, appealing address/Fax# and timely filing limit to send a corrected claim or appealing limit to appeal the claim.
6	Send the claim to coding team to review the claim. If they correct the claim, then update and resubmit the claim as corrected claim.
7	If coding team says submitted claim is already correct, but still insurance denied. Then appeal the claim with supporting documents.
8	If appeal withheld, then submit the claim to secondary or consecutive payer along with primary EOB. (Note: If patient has secondary insurance, then we need to take further action based on secondary insurance outcome.)
9	If no consecutive or secondary payer, then bill patient, if it is not covered as per patient plan.	If no consecutive or secondary payer, then we need to adjust the claim, if it is not covered as per provider contract.
Denials and Action List

18

Denial Code CO 97 – Claim denied as Inclusive/Bundled/Mutually exclusive
1	May I know to which CPT code it is inclusive/bundled/mutually exclusive?
2	Check with rep, to which DOS (same service/different service) it is inclusive/bundled/mutually exclusive. If it is for different DOS, then get the date of service details.
3	If CPT is inclusive with surgery code, then we need to check for global period. If the procedure billed between the global period range, then it should be written off but there are chances to separate out the inclusive procedure code with surgery code by adding appropriate modifier. So, assign those inclusive claims to coding team to review the claim once before taking further action.
4	Get both Corrected claim mailing and appealing address and their timely filing limit?
5	Assign claim to coding team to review the claim and to check if can update the claim with appropriate modifier.
6	If coding team corrects the claim with appropriate modifier, then resubmit the claim to insurance company as corrected claim.
7	If coding team states the coding is correct, then appeal the claim to insurance company along with supporting documents.
Note: If appeal withheld, then we need to write off that procedure code (so assign it to client for further action).
		Denials and Action List

19

PR 119 Denial Code – Maximum benefit exhausted
1	May I know the Maximum Benefit reached in terms of dollar amount or number of visits?
	If the maximum benefit reached in terms of dollar amount, then follow the below instructions:	If the maximum benefit reached in terms of visits per year, then follow the below instructions:
2	May I know how much dollar amount allowed per year?	May I know how many visits are allowed per year?
3	May I know how much dollar amount insurance has paid so far and on which DOS the patient has met the maximum dollar amount? (Check application to see if patient has met the maximum dollar amount previously).	May I know how many visits patient met so far and on which DOS the patient has met the maximum visit? (Check application to see if patient has met the maximum visit per year ).
4	If patient has not reached the maximum benefit dollar amount or maximum visits per year, then request rep to send the claim back for reprocessing and ask for the processing time.
5	If patient has met the maximum benefit dollar amount or maximum visits per year, then we need to check for secondary or consecutive insurance company for patient. If available, then submit the claim along with primary EOB.
6	If secondary or consecutive insurance not available for DOS, then go ahead and bill the claim to patient.
		Denials and Action List

20

PR 197 Denial Code – Claim denied for Missing/invalid/Authorization/Notification/Pre-certification
1	Whenever you get this denial first step is to check in system for authorization number. If authorization number found for the service rendered then follow the below steps: Call claims department and request rep to send the claim back for reprocessing by providing the valid authorization number available on file.
	If rep agrees and send the claim back for reprocessing, get the processing time?	If rep disagree to send the claim back for reprocessing, then get the corrected claim mailing address and timely filing limit to resubmit the corrected claim along with valid authorization number.
2	If authorization number not found in the system or if it is invalid, then check for the place of service. If the place of service is 23, then send the claim back for reprocessing stating emergency service does not require an authorization. Get the reprocessing time?
3	If suppose the place of service is not 23, then ask rep. Do you have any authorization number on file? If yes, then ask the rep to send the claim back for reprocessing with that authorization number available. (If rep disagree to send the claim back for reprocessing, then get that authorization number, corrected claim mailing address and timely filing limit to resubmit the corrected claim.)
4	If No authorization number on their side, then ask rep is there any hospital claim received on this Date of service? If yes, then check is there any authorization number billed on the hospital claim? If yes, then send the claim back for reprocessing with that authorization number and get the processing time.
5	If rep disagree to send the claim back for reprocessing with that hospital claim authorization number, then then get that hospital claim authorization number, corrected claim mailing address and timely filing limit to resubmit the corrected claim
6	If no hospital claim found or no authorization number in hospital claims, then ask rep whether we can obtain retro authorization? If yes, get the phone number of retro department to obtain retro authorization number.
7	If retro authorization not possible for the claim, then get the appealing address and time frame to appeal the claim.
Note: If valid authorization not available for the DOS, Retro authorization not possible and appeal was withheld then we need to write off the claim.
		Denials and Action List

21

PR 226 Denial Code – Claim denied for Medical Records
1	May I know what Medical Records is required for this service?
2	Check the previous notes in application to see whether medical records already sent to the payer as requested.
3	If medical records not sent, then get the claim mailing address or fax number and time frame to submit the requested medical records
Note: If no medical records found in the application, then escalate the claim to client for medical records. Once medical records received from the client, we need to attach and submit it to the insurance.
	Denials and Action List

22

B9 Denial Code – Claim denied by Medicare as patient enrolled in Hospice
1	May I know the start and End date of the Hospice?
2	Get the Hospice Name, NPI, address and contact number.Then submit the claim with medicare ID or SSN# to Hospice.
Medicare beneficiary with Part A benefits can elect hospice services under the hospice benefit provision, if the patient has a life expectancy of 6 months or less to live. When physician provides services to hospice enrolled patients. Physicians claim are not payable by Medicare directly because physican claims are covered under Medicare Part B and Hospice are covered under Medicare Part A. Payment of Hospice services to physcian and hospital claims are included in hospital claims, so physician needs to submit the claim to the hospital directly. If claims submitted to Medicare during the period patient enrolled in hospice, then those claim will be denied by Medicare with denial code CO B9 stating patient enrolled in Hospice. 1) Modifier GV  is used when a provider is rendering services that are related to diagnosis for which a patient is enrolled in Hospice. 2) Modifier GW is used when a provider is rendering services that are not realted to diagnosis for which a patient is enrolled in Hospice.
Note: Sometimes insurance does not provide hospice information and they give only NPI number. In such case use NPPES website to obtain Hospice information.
		Denials and Action List