Saturday, June 30, 2012

Denial and Action for PR 96 and CO 170

CO/PR 96 Non-covered charge(s)


Resources/tips for avoiding this denial

There are multiple resources available to verify if services are covered by Medicare we can use that resources. Check the Medicare NCCI Edit and make sure that CPT and ICD combination are matching.

Tips to correct the denied claim

This denial is not usually able to be corrected.

• If you are submitting non-covered services to receive a denial for secondary or supplemental insurance, ensure to bill services with the modifier GY, indicating "statutorily non-covered services." Generally secondary insurance would cover these rejection.

 *  Check the possibilities of adding Modifier and changing the DX as per Medical record.

The acutal meaning for this denial is Billing for services not covered under the contract.

This could be differentiated between Providers’ and Patients’ Contract

All carriers have their list of Non-covered services mentioned in the Providers’ & Patients’ handbook / manual.

This also includes about Providers’ participation with the carrier and the insureds' (patients’) choosing of one such provider who participates.

Challenge:  Biggest challenge is to identify and differentiate the exact denial information from the EOBs/ERAs about the claim to handle.

Categories: Non-Covered denial is grouped majorly under the following categories by the carriers

Patient Related Concerns :

When a patient meets and undergoes treatment from an Out-of-Network provider

Action to be taken – Based on Provider’s consent bill patient either for the whole billed amount or the carrier’s allowable. Cross verify in the EOB if the payment has been made to the patient directly. If yes, please bill the patient without any delay.

Preliminary Action to avoid delay in billing patient – Prior verification notes should explain in detail for the front desk executive so that they could inform patient about provider’s participation. In most cases they would avoid seeing those patients except for an emergency need – [Process already in place with Verification Dept]. 

Similarly, cross verify with the insurance if the payment would be made to the patient if the claims are filed. If yes, pls document the same in the notes and alert the front office to collect the calculated (calculate separately based on the CPT's allowed amt) amount from the patient at the time of service

Any services not listed under the patients’ benefit package

Action to be taken – Bill patient directly

Preliminary Action to avoid delay in billing patient – While posting denial set the Denial description to reflect directly on the patient statement format.  And generate either electronic or manual patient statement for despatch immediately

When patients’ age criteria is not met

Action to be taken – Either patient age should have been incorrectly updated in the Demo else we would have picked CPT irrelevant to the patient’s age.  Double confirm the correct and required information with coding team and refile the claim

Preliminary Action to avoid delay in Reimbursement – Set AGE criteria in the CPT Master set up.  This set up will alarm the charge posters while saving the CPT code that is irrelevant to the patient’s age.

{Note:  1. Provider’s may also instruct us to waive the balances for First 2 Cases in that situation we have take write off while posting denial actions or while AR review, with appropriate “Write Off code” as “W/O taken for Non-Covered services based on Provider’s Consent”

2. All the actions should be recorded in the Follow up notes section of your system with received denial, appropriate action to it and a follow up date set (if reqd)}

Coding Related Concerns :

ICD – LCD guidelines not met
Multiple procedures performed on the same day billed
Invalid POS/type billed
When a service is performed within a period of time prior to or after inpatient services
Invalid NDC code
Inclusive to primary procedure billed
Invalid CPT billed and Others

Action to be taken – Initiate claims towards Coding Dept for review.  Based on coders’ response take appropriate action on the claim.

Preliminary Action to avoid action delay in Reimbursement – 

ICD – Valid DX set up within CPT Masters could be enabled and in-turn the CPT code could be tagged within the Insurance Masters.

System will alert us with a warning message stating “CPT already entered for this date – Do you want to continue” Within CPT Set up Master we would specify valid POS (Place of service) and TOS (Type of service) Prior billed services could be viewed under “Bill” from the Charge posting screen

Drug Set up could be utilized in order to fix NDC# specific to plan and procedures.

Modifiers to avoid Inclusive Denials could be specified in the CPT Master setup
Inactivate all the invalid or deleted CPTs from the CPT masters 

Provider Related Concerns :

When service is not related to Providers’ specialty

Action to be taken – Inform provider about the procedure listed in the superbill and suggests an alternate active CPT code to be billed - to be done during coding and charge entry process itself before claim submission.

Preliminary Action to avoid action delay in Reimbursement –
Coding screening could be done on prior hand so that these could be immediately identified and escalated to the Provider.

Non-covered services listed by the Carriers billed

Action to be taken – List the services which are denied for the given reason from specific carriers and forward it to client for W/O approval.. Note:  Ensure that we have billed the CPTs correctly.

Preliminary Action to avoid action delay in Reimbursement – 

 Procedures listed in the scheduler should be verified prior to charge posting.  So that providers will be aware of the Non-covered services prior to billing.
Same service already been billed and paid to another provider

Action to be taken – Follow up with the carrier and get the details of prior claim which was billed and paid to the other provider.  Ensure to get the information of the other provider billed for the same service.  Also make sure that no component of that claim is payable but missed to be collected by us. Compile the list and forward it to client for approval of W/O

If provider is not participating with the carrier

Action to be taken – Credentialing process to be initiated and affected claims are to be compiled and sent for provider’s approval for W/O

Preliminary Action to avoid action delay in Reimbursement – 

Providers participation details are to be verified during verification process
Front Desk executives are to be alerted through Alerts/Instructions within the system Until credentialing process is completed we could hold our claims to avoid denial on participation.

CO 170 This payment is adjusted when performed/billed by this type of provider.

(THIS SERVICE BY A CHIROPRACTOR IS NOT COVERED BY MEDICARE) . Provider type does not match type required by benefit

Resources/tips for avoiding this denial

Chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered.

This type of provider can't be performed this service hence please check the procedure CPT code and change it if any mistakes happened or else we it should be adjustment.

Tip to correct the denied claim

Services not covered by Medicare should not be billed to Medicare.

• Billing denied services to Medicare for coordination of benefits is allowable.

If our provider keep on doing this procedure means, contact insurance and include this procedure CPT code in the contract.

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