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Wednesday, September 21, 2016

Denial code CO 197 & N347, N20


CO-197 -Precertification/authorization/notification absent.

Some of the  carriers request to obtaining prior authorization from them before the serivce/surgery.  This may be required for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific.  Please note that it is the responsibility of the Physician/Surgeon and not the patient to obtain the authorization# from the carrier.

When you get a denial from the carrier for this reason, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.


For some major procedureor all procedures or carrier specific we have to obtain the Pre Certification or Prior Authirization before the service performed. This is purely responsible of the Physician or Surgeon and not the  patient have.

If we received this denail from the carrier, first we need to check the system if any note/alert entry has been made for the patient for the DOS concerned and for the procedure in question. Always verify the entire notes/document since we might have already have it in systme. If we have the PreCerfication/Prior Authization document was scanned or uploaded in the PMS then w ehave to update that and resubmit the claim as corrected claim. But make sure todouble comfirm that it should be for the respective DOS and its valid for the DOS. If a valid auth# is found indicate the same else mention the source file name and pg# of the original file along with the PCP’s name and phone#.

Then call the PCP to get the Authorization, once we received then update and submit the claim for reimbursement.




REMARK CODES & REASON:

N20 - Service not payable with other service rendered on the same date.

N347 - 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.

M86 - Service denied because payment already made for same/similar procedure within set time frame

If we received   “Duplicate” denial with the above remark codes, we have to check the below check points.


Need to check if this same procedure/service was rendered/paid to another provider.
Need to submit with appropriate modifier (76/77) after confirmation with Coding Team. Even for EKG 93010 we get Duplicate denial, since we are billing repeatedly this code with combination of 93010-without modifier, 93010 -59,9310-59&76, 93010-76 (Based on EKG document performed timing) same DOS - Cardiology specialist.


DUPLICATE  DENIAL CODE WITH DESCRIPTION:

18 - Duplicate claim/service.

Reason for Denial 

Insurance received the same claim more than one time.
Actions for Denial
Check the system whether the claims has been already paid/denied if  yes ignore the denial or follow the below one.
Check the denial history and resubmission history if we submitted the claim more than once without any changes (same dos, procedure, diagnosis code and doctor.)  please resubmit the claims with necessary changes as corrected claim.
If no payment or denial in the claim, we have to get the original claim status through calling or Online
To avoid this denial in the future

If any correction like append modifier/ICD changes/corrected Referring physician/obtained Auth/Referral/Changes in Units/Changes in Billed Amount we have update the claim as “CORRECTED CLAIM” in software. (CMS 1500-CLAIM NOTE Tab)

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