Eligibility related denial claim

Denial - BENEFICIARY ELIGIBILITY

Description: 

You submit a claim for processing and the beneficiary/patient does not have Medicare eligibility. Claims are often denied for eligibility for the following reason:
* The beneficiary Medicare number is invalid on the claim.
* The beneficiary is not eligible to receive Medicare benefits.
* The beneficiary's claims must be filed to another insurance plan.



Action :
Screen your patients. Verify the Medicare number on the patient's Medicare card and file the claim exactly as it is printed on the card. Verify the patient's effective date for Medicare Part B from their Medicare card. Medicare cannot pay for services prior to the patient's effective date and will not pay for services if the patient has terminated his Medicare benefits. Beneficiaries who enroll in a Medicare "replacement" HMO must be submitted to that insurance plan instead of Medicare Part B. To obtain Medicare eligibility, call your carrier's Provider Service department.

Insurance denial - IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

IMPROPER DIAGNOSIS or INCORRECT DIAGNOSIS

Description:
Services were denied because the diagnosis listed as primary was not a covered diagnosis for the procedures performed.

ACTION:

Check your specific carrier's local coverage determination (LCD) policy for the specified procedure to obtain a list of covered diagnoses, generally found on their Web site, or accessible on Medicare's Web site. Also familiarize yourself with the appropriate policies for medical necessity and documentation requirements. Be cautious of automated programs/software that provide a covered diagnosis for any given procedure. Keep in mind that having a covered diagnosis does not mean you can automatically perform any procedure for which the covered diagnosis exists. You must prove and document the reason in the medical record to justify doing the procedure. For example, let's look at doing routine anterior segment photography because your patient presents with allergic conjunctivitis. Despite having a "covered diagnosis" for taking the photo, there most likely is insufficient medical necessity to take an annual photo of the allergic eye.

Denial claim reason - MISSING A MODIFIER OR HAS AN INCOMPLETE OR INVALID MODIFIER :

THE CLAIM IS MISSING A MODIFIER OR HAS AN INCOMPLETE OR INVALID MODIFIER :

Description: 

The modifier necessary to process the claim correctly is either missing, incomplete, or invalid for the specific procedure and diagnosis indicated on the claim form.

Action:

Know the proper use of the CPT modifiers that exist and are appropriate to use for the specific condition or situation. The CPT modifiers are listed in their entirety in Appendix A of the current version of the CPT Manual. You can obtain the CPT manual from the American Optometric Association or from the American Medical Association. You should also know that misuse and abuse of modifiers are under the scrutiny of the Office of Inspector General (OIG) and that can result in significant penalties.

Insurance deny the claim - PROVIDER NUMBER IS MISSING OR INCOMPLETE

PROVIDER NUMBER IS MISSING OR INCOMPLETE

Description:

CMS1500 form Items/Box #24K and #33 are filled out incorrectly, with the UPIN (unique provider identification number) or information is missing, thus causing a denial of the claim.

Action :

 For item 24K, enter the personal identification number (PIN) or national provider identifier (NPI) of the performing provider of service/supplier if you are a member of a group practice. When several different providers of service or suppliers within a group are billing on the same form CMS-1500, show the individual PIN or NPI in the corresponding line item.

For item #33, enter the provider of service/supplier's billing name, address, ZIP code, and telephone number. These are required fields. Enter the PIN (or NPI when implemented), for the performing provider of service/supplier who is a member of a group practice. Suppliers billing the DMERC should use the National Supplier Clearinghouse (NSC) number in this item. Enter the group UPIN, including the two-digit location identifier, for the performing practitioner/supplier who is a member of a group practice.

Insurance denial -CO- 182/CR - 182 Payment adjusted because the procedure modifier

CO- 182/CR - 182 Payment adjusted because the procedure modifier was invalid on the date of service.


Definition :MODIFIER REQUIRED/INVALID MODIFIER

 Action:   First check whether modifier has been entered at the time of charge entry. If no, then resubmit the claim with the correct modifier. If modifier has been entered but the carrier rejects the same then check whether the correct modifier has been used. If you find that the correct modifier has been used, then call the insurance and find out the reason for rejection. Based on the feedback, take corrective action. One example, Blue choice (New York) rejected a lot of claims for the reason invalid or missing modifier. Carrier was called and it was found that they do not require modifiers hence forth and claims need to be billed without modifiers.

Q: We received a RUC for the claim adjustment reason code (CARC) CO182. What steps can we take to avoid this RUC code?

The procedure code modifier submitted on your claim is not valid for the date of service billed

A: You are receiving this reason code when a claim is submitted and the procedure code(s) are billed with the wrong modifier(s), or the modifier(s) is no longer valid for the date of service billed. A clear understanding of Medicare’s rules and regulations is necessary in order to assign the appropriate modifier(s) correctly.

What is a procedure code modifier?

A modifier is a two-position alpha or numeric code that is added to the end of a Current Procedural Terminology® (CPT) or Health Care Procedure Coding System (HCPCS) code to provide additional information or to clarify the service(s) being billed.

Important Review Facts

• Before submitting your claim, ensure you use the most current year's Current Procedural Terminology® (CPT) codes and modifiers.

• Know the proper use of the CPT modifiers that exist and the appropriate use for the specific condition or situation.

• Check the claim to verify if an applicable modifier(s) is warranted and has been applied to the procedure code billed.

• Providers can utilize the Modifier lookup tool which provides information for most procedure code modifiers used by Medicare.

• If a modifier has been entered but the Medicare contractor rejects the claim, you should verify that the correct modifier(s) has been used.
Example:

Modifier 26 may be used to indicate that the professional component is reported separate from the technical component (TC modifier) for certain diagnostic test and radiology services. Codes that do not have both a technical and professional component (such as laboratory codes) should not be billed with modifier 26.

• Correct billing: The 26 modifier (professional service) may be used when billing procedure code G0202 (digital screening mammography). The listed diagnostic procedure has both a professional and technical component.

• Incorrect billing: The 26 modifier (professional service) is not permitted when billing procedure code 80048 (basic metabolic panel). The listed laboratory code does not have a professional and technical component.

• Submit separate claims for services in different years of service. A procedure code or modifier valid in one year may not be valid in the other and will cause the entire claim to reject or deny.