Thursday, July 8, 2010

Claim denied as - inclusive, maximum per unit, injury liablity and pre existing

Claim denials for maximum units per visit

Check your units of the CPT. Check LCD Guidelines for Maximum unit. We can appeal the claim with document supports for additional units of service.

Sometime claim submitted with wrong units by mistakes, correct the unit and resubmit the claim.

Dialysis Services requires one service line per a date of service with a maximum unit of one for dialysis services. If a claim is received with a date span billing multiple units on a single charge line, the charge line will be denied



Claim denied as inclusive with the primary procedure

Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.

Check whether its a mutually inclusive CPT, If not resubmit with appropriate Modifier or changes in ICD code. If it is Bundled CPT code, please write off it.




Claim denied due to pre-existing condition
Member has Preexisting Condition on DOS for Diagnosis

Patient needs to update the medical (medical history) document to insurance and provider also update the medical document to insurance. as soon as you receive the denial,  check with insurance on the pre-existing condition. If the patient has secondary coverage with the secondary if we can send the entire bill to secondary along with the primary denial.  Some carriers may be willing to pay for the same.  If the patient has no secondary coverage/ secondary refused to pay the request you to bill the patient.



Claim denied as services not provided or authorized by designated

File the claim along with appropriate authorization#. Check all the documents as sometime Authorization number has been mentioned in Medical record. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.




Claim denied because of incorrect medical coding
Should be file the claim with correct diagnosis (Dx) and CPT



Claim denied because this injury is the liability of the no-fault carrier.

Should be file the claim to patient auto-insurance.



Claim denied by medicaid because primary insurance changed

File the claim to patient primary insurance. If we don’t have patient primary insurance details needs to call the patient and get the insurance information.



Claim denied by medicare for code co-16 what do i do to get this paid?
      We will receive this denial if we have filed the claim with insufficient information. This code co-16 must have additional denials information that informs us what kind of information is missing with claim.





Claim denied for clia certification#
Should be file the claim with clia certification number. We must file the lab code with clia number.

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