Monday, June 13, 2016

How to avoid denial PR 27 AND CO 22

PR 27  Expenses incurred after coverage terminated


Resources/tips for avoiding this denial
Services were denied because the patient didn't have Medicare Part B coverage at the time the services were performed.
• Obtain a copy of the patient’s most recently issued Medicare card to compare with the number you are submitting. Via the Medicare card, verify for which part(s) of Medicare the patient is eligible.
• Before submitting a claim, check the patient's eligibility for current and previous service date

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 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.

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