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?

                                                                                   ↓
                                                                          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?

                                                                         Claim# & Call ref#?              ↓
                                                                                                             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:

* Call Website EOB System

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?:

* Yes No

What is different?:

* Modifiers are different Rendering doctors are different Exam times are different Medical records are different Modifiers and rendering doctors are different

Rep agreed to reprocess?:

* Yes No

TAT for Reprocessing:

*

Reason for not reprocessing the claim:

* Need to Send Corrected Claim Need to Send an Appeal

Next Action:

* Need to Send Corrected Claim Need to Send an Appeal

Time frame to send corrected claim?:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Appeal Limit:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Updated 77 modifier and resubmitted the claim Updated 76 modifier and resubmitted the claim Updated the modifier and resubmitted the claim Need to allow time Need client assistance Need to submit an appeal Appeal sent Write off the claim Voided the claim



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