18: Exact duplicate claim/service
Denial Occurrence:
- This denial occurs when the same service on the same date of service is billed more than once.
- This denial also occurs if the claim is billed twice in an error. In this case, the first billing claim gets processed and the second one gets denied as duplicate service.
On Call Scenario:
Claim denied as duplicate
↓
May I get the denial date?
↓
Check if CPT of your charge billed
more than once on same DOS
↙ ↘
No Yes
↙ ↓
What is the original Check if modifier, rendering provider
status of the claim? and exam time on medical records are same
↓ ↙ ↘
Follow AR scenario tool No Yes
for original claim status ↓ ↓
Click Here Can you please reprocess May I have the
the claim since modifier, claim# & call ref#?
rendering provider or exam time
on medical records are different?
Claim denied as duplicate
↓
May I get the denial date?
↓
Check if CPT of your charge billed
more than once on same DOS
↙ ↘
No Yes
↙ ↓
What is the original Check if modifier, rendering provider
status of the claim? and exam time on medical records are same
↓ ↙ ↘
Follow AR scenario tool No Yes
for original claim status ↓ ↓
Click Here Can you please reprocess May I have the
the claim since modifier, claim# & call ref#?
rendering provider or exam time
on medical records are different?
↓
Rep Agrees?
↙ ↘
Yes No
↙ ↙ ↘
What is the TAT Rep asked to Rep asked to
for reprocessing? send corrected submit an appeal
↓ claim ↓
May I have the ↓ What is the Fax# or
claim# & call ref#? What is the Mailing address to
time frame for send an appeal?
Rep Agrees?
↙ ↘
Yes No
↙ ↙ ↘
What is the TAT Rep asked to Rep asked to
for reprocessing? send corrected submit an appeal
↓ claim ↓
May I have the ↓ What is the Fax# or
claim# & call ref#? What is the Mailing address to
time frame for send an appeal?
corrected claim? ↓
↓ How much is the
May I have the time limit?
↓ How much is the
May I have the time limit?
Claim# & Call ref#? ↓
May I have the
Claim# & Call ref#?
Important Notes & Actions:
May I have the
Claim# & Call ref#?
Important Notes & Actions:
- Please take action as per your process update. Below actions can be different from your process update.
- If the same CPT is not billed more than once on the same DOS then ask for the original claim status and follow the AR Scenario based on the denial reason.
- If the same CPT is billed more than once on the same DOS and modifier, rendering provider & exam time on the medical records are not same and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
- If the same CPT is billed more than once on the same DOS and modifier, rendering provider & exam time on the medical records are not same and the rep denies reprocessing the claim and asks to send a corrected claim then update the correct modifier and submit the corrected claim by updating the correct billing code "7" along with the claim number.
- When rendering providers on the charges are different then add 77 modifiers and resubmit the corrected claim.
- When rendering providers on the charges are the same but the exam times are different then add 76 modifiers and resubmit the corrected claim.
- After sending the corrected claim, if the claim is again denied for the same reason and the insurance rep denies reprocessing the claim then send an appeal to insurance.
- When modifiers on the charges are different and the rep denies reprocessing the claim then send an appeal to insurance.
- Medicare does not accept the corrected claim, so send a fresh claim to Medicare.
- If the same CPT is billed more than once on the same DOS and modifier, rendering provider & exam time on the medical records are not same and the rep denies reprocessing the claim and asks to send an appeal then send an appeal to insurance.
- When sending an appeal, calculate the time limit from the denial date, if it is not crossed then send the document, or else write off the claim if the time limit is crossed.
- Sometimes the client wants us to send the document even if the time limit is crossed, so work accordingly.
- If the same CPT is billed more than once on the same DOS and modifier, rendering provider & exam time on the medical records are the same then the charge should be voided.
- Sometimes, the client wants us to get the coding team clarification to determine whether these are duplicate charges or not, so work as per client instructions.
- Click here to go to Quiz
Prepare Notes:
Source of Status:
Clearing House Comment (Please make the changes if required):
Insurance Name:
Clearing House Name:
Insurance Phone#:
Rep Name:
Website Name:
Denial Date:
Is the smae CPT billed on the same DOS has same modifier, rendering provider, exam time and medical records?:
What is different?:
Rep agreed to reprocess?:
TAT for Reprocessing:
Reason for not reprocessing the claim:
Next Action:
Time frame to send corrected claim?:
Mode of appeal:
Fax Number:
Website Link:
Appeal Limit:
Mailing Address:
Additional Comment:
Claim Number:
Call Reference#
Action:
In the below box, final notes will be displayed once you click on Submit button and this box is editable, so you can make the changes as per the requirement
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while using Epic software sometimes duplicate also feels very hectic when we check details when we go on call with rep
ReplyDeleteWhat is the exact issue? Is it not possible to see all the charges billed on the same date easily?
DeleteNo
Deleteyea true bro epic is headache when comes to duplicate
DeleteWe are not aware of this software but if the percentage of these denial claims is high then you can explain the issues that you are facing to your client. They will definitely look into it and provide a solution.
DeleteFor denial code N425 what action can we take?
ReplyDeleteM425: Statutorily excluded services are not payable. You can take the help from coding team for an alternate CPT.
DeleteBut, if there is no alternate CPT then it can be billed to the patient if ABN is signed by the patient or else it needs to be written off.
Oa 18 amd oa23 both denials on the claim which one to consider
ReplyDeleteIf the claim is billed twice and for the first submission, it is denied for OA23 and for the second submission, it is denied for 18 then you can consider denial 23 and work on it.
DeleteActually, it is very difficult to tell you to consider any denial without analyzing it. It may have previous work that also needs to be considered.
Need to ask which provider's claim first you received?
ReplyDeleteIf both the claims have different providers then you can append 77 modifier on the denied claim to get it paid.
DeleteDon't go to night shift it will affect your brain.
ReplyDeleteThen please suggest any day JOB in AR
DeleteAR morning shift available in US.
Deletewow
ReplyDelete