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Friday, June 11, 2010

PR 22 - This care may be covered by another payer

PR 22 This care may be covered by another payer per coordination of benefits.

Reason for Denial

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. Medicare require primary EOB.

No COB entered with a secondary enrollment PEND Resubmit with primary EOB

Pend claim if COB is 0 on secondary enrollment claim PEND Resubmit with primary EOB

Medicare Excluded Service - Other Insurance Dollars on Claim

No COB amount on claim PEND EOB needed to review

Potential other accident WARN Might be covered by another payer

Medicare Crossover QMB Processing Rules Applies DENY

No COB Amount on TPL Dental PEND

No TPL Dollars Submitted on Medicare Claim

Tips for avoiding this denial :

Denial indicates Medicare’s files show the patient has another insurance primary to Medicare (called Medicare Secondary Payer or MSP).

Before submitting a claim to Medicare:


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.


Have your patient complete the Medicare Secondary Payer (MSP) Questionnaire to help determine if Medicare is the primary or secondary payer.

Check the patient’s eligibility, including if Medicare is a secondary payer, via the Part B interactive voice response (IVR) system.

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

When a patient's file indicates Medicare is not the primary insurance, submit the claim to the primary payer; once it is processed, a claim can be submitted to Medicare for possible secondary payment.


Tips to correct the denied claim

* Submit the claim with primary EOB

Contact the patient to determine if any change has occurred in their insurance status. You can complete the Medicare Secondary Payer (MSP) Questionnaire to help determine if Medicare is primary or secondary.

If so, update the insurance information on your files for all future claims.

If you have information the patient's MSP file is incorrect, the patient and/or the provider should contact the Coordination of Benefits Contractor (COBC) to update the file.

If the patient's file has been updated to reflect Medicare as primary on the date(s) of service, resubmit the claim to Medicare.

If Medicare is secondary, submit the claim to the primary payer; once it is processed by the primary insurance, a claim can be submitted to Medicare for possible secondary payment.

 

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