Tuesday, June 8, 2010

Covered by another payor - CO 22 & 23 - Insurance denial N598

CO 22 Payment adjusted because this care may be covered by another payer per coordination of benefits. /  This care may be covered by another payer per coordination of benefits.

Explanation :

Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

Reason for Denial 

Patient has another insurance as primary.
Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.
Patient has to update COB information, since patient has two insurance but they haven’t updated which is primary.

Solution:

This denial indicates the beneficiary has an insurance primary to Medicare on file.

Contact the patient to determine if any change has occurred in their insurance status. You can also check through eligibility verification to determine if Medicare is the patient's primary or secondary insurance.

Once this analysis is complete, update the insurance information on your files for all future claims.

You may contact the Coordination of Benefits Contractor (COBC) and update the patient’s files by conducting a conference call with the patient.



Actions 

Verify the insurance details by checking Patient Document (for Card copy or any other document), Online, IVR or calling the beneficiary.

Once we found which is Primary then we have to Submit the claim directly to the payer.

For COB conflict we have to call patient if the balance is HIGH, inform to update COB information to payer or else we can directly bill the patient and sending statement if its small balance or is for the first visit.



CO-22 This care may be covered by another payer per coordination of benefits.
N598 Health care policy coverage is primary.

Common Reasons for Message

    Patient has another insurance primary to Medicare
    Patient's coordination of benefits is not up-to-date

Next Step

    After billing primary insurance, submit secondary claim to Medicare
    If patient's coordination of benefits has been updated to reflect Medicare as primary, submit primary claim to Medicare

 Claim Submission Tips

    For electronic claims, verify that all necessary primary information is correctly submitted on claim

 Verify patient's eligibility via Interactive Voice Response (IVR) or the Noridian Medicare Portal

    If there is a problem with file, patient may contact Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627 to make necessary corrections

Prior to rendering services, obtain all patient's health insurance cards

Ask beneficiary to fill out Admission Questions to Ask Medicare Beneficiaries [PDF] form



To avoid this denial in the future

While doing verification, we have to check this information and Alert the Front Desk executive through system Alert. So that they will inform patient or collect payment from patient for the service.


Check if the patient has Group Health Plan coverage that primary to Medicare

If the patient has GHP group coverage resubmit the claim with documentation EOB.

If the patient does not have the GHP or any other insurance ask patient to contact COB benefit contractor of Medicare.



Here are steps you can take to help avoid this denial in the future:

Periodically, have your patient(s) help you determine if Medicare is the primary or secondary payer.

Check your patient’s eligibility, including if Medicare is a secondary payer, via the IVR.

If Medicare is secondary, the IVR will list the following MSP details:

1. Type of primary insurance

2. Effective and termination date for all valid Insurers for a current or previous date of service.

Q: We received a denial with claim adjustment reason code (CARC) CO 22. What steps can we take to avoid this denial?

This care may be covered by another payer per coordination of benefits.

A: This denial is received when Medicare records indicate that Medicare is the beneficiary’s secondary payer.

To prevent this denial in the future, follow these steps before submitting claim to Medicare. If Medicare is the secondary payer, send claim to primary insurer for a determination before submitting to Medicare for a possible secondary payment.

• Ask patient/representative to complete the Medicare Secondary Payer (MSP) Questionnaire external pdf file to help determine if Medicare is the primary or secondary payer.

Check patient eligibility and verify if Medicare is the secondary payer via the Secure Provider Online Tool (SPOT) or the interactive voice response (IVR) system. If Medicare is secondary, the following MSP details will be provided:

• Via SPOT:
• Effective date
• Termination date
• Insurer name
• Policy number
• Type of primary insurance
• Address
• Via IVR:
• Type of primary insurance
• Effective and termination date for all valid insurers for a current or previous date of service.


To resolve the denial:

• Contact patient/representative and ask if patient insurance has changed. The Medicare Secondary Payer (MSP) Questionnaire external pdf file may also be completed at this time to help determine if Medicare is primary or secondary.

• If patient insurance has changed, update your files for future reference.

• To update patient Medicare records, you may place a conference call with the patient/representative and the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.

• If patient file is updated to indicate that Medicare is the primary payer on the date(s) of service, resubmit the claim to Medicare.

• If Medicare is secondary, submit the claim to the primary payer for processing. After determination is made by the primary insurer, submit claim to Medicare for possible secondary payment


Medicare Guide for working on Denial code CO 22

A: This denial is received when Medicare records indicate that Medicare is the beneficiary’s secondary payer.

To prevent this denial in the future, follow these steps before submitting claim to Medicare. If Medicare is the secondary payer, send claim to primary insurer for a determination before submitting to Medicare for a possible secondary payment.

• Ask patient/representative to complete the Medicare Secondary Payer (MSP) Questionnaire external pdf file to help you determine if Medicare is the primary or secondary payer.

Check patient eligibility and verify if Medicare is the secondary payer via the Secure Provider Online Tool (SPOT) or the interactive voice response (IVR) system. If Medicare is secondary, the following MSP details will be provided:

• Via SPOT:
• Effective date
• Termination date
• Insurer name
• Policy number
• Type of primary insurance
• Address
• Via IVR:
• Type of primary insurance
• Effective and termination date for all valid insurers for a current or previous date of service.

To resolve the denial:

• Contact patient/representative and ask if patient insurance has changed. The Medicare Secondary Payer (MSP) Questionnaire external pdf file may also be completed at this time to help you determine if Medicare is primary or secondary.

• If patient insurance has changed, update your files for future reference.

• To update patient Medicare records, you may place a conference call with the patient/representative and the Benefits Coordination & Recovery Center (BCRC) at 1-855-798-2627.

• If patient file is updated to indicate that Medicare is the primary payer on the date(s) of service, resubmit the claim to Medicare.

• If Medicare is secondary, submit the claim to the primary payer for processing. After determination is made by the primary insurer, submit claim to Medicare for possible secondary payment.





CO 23 Payment adjusted because charges have been paid by another payer. 

OA - 23-The impact of prior payer(s) adjudication including payments and/or adjustments.

The impact of prior payer(s) adjudication including payments and/or adjustments.

** Member might have other coverage

Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer.

This denial is received when a service, which has been indicated as being purchased from another provider, is showing having already been paid to another provider elsewhere.


Reason for Denial
This denial we received only from secondary payer.

Action for denial
Check if the insurance is Primary or Secondary- If its from Primary payer then we have to bill patient since patient need to update COB information to the  Payor

If its Secondary - then we have to waive the coinsurance balance. Some client wants to bill the patient. We need to act based on the client specification.


Q: We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.
• Medicare claims must be submitted to the MA plan.
• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.
• Obtain eligibility and benefit information prior to rendering services to patients.
• Ask patients if they have recently enrolled in any new health insurance plans.
• Request to see a copy of all of their health insurance cards.
• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.
• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).
• Claims that are returned as unprocessable cannot be appealed,

End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.

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