96: Non-Covered Charges

Denial Occurrences:

• This denial has 2 categories:
• Non-covered charges as per patient plan
• Non-covered charges as per provider contract

• Non-covered charges as per patient plan: This denial occurs for below reasons,
• Provider is out of network
• Non covered DX or ICD-10 code under patient policy
• Non-covered CPT code under patient policy

• Non-covered charges as per provider contract: This denial occurs when the CPT code is non-covered under the provider contract.

On Call Scenario:

                                          Claim denied as Non Covered Charges
                                                                             ↓
                                                         May I get the denial date?
                                                                             ↓
                                  Is it non covered as per patient plan or provider contract ?
                                      ↙                                                                            ↘
              Non covered as per patient plan                            Non covered as per provider contract
                                     ↓                                                                                  ↓
            What is the reason for non covered?                       What is the reason for non covered?
                   ↙                  ↓                   ↘                                        ↙                                   ↘                 
     Provider is        DX or ICD-10       other                 CPT non covered under            Other reasons 
   out of network     non covered        reasons                   provider contract                              ↓
             ↓                         ↓                      ↓                                     ↓                                   Follow AR
    Click Here          What is the          May I               Check payment history             Scenario Tool 
                               time frame to       have the       if payment received for same           Click Here
                                  submit the        claim# &      CPT with same provider from
                            corrected claim?    call ref#?                  same insurance
                                        ↓                                           ↙                                   ↘
                             May I have the                        Yes                                            No
                             Claim# & Call                          ↓                                                ↓
                                     ref#?            Could you please send claim          What is fax# or Appeal
                                                          back for reprocessing since        address to send the appeal?
                                                        we have received payment for                        ↓
                                                                   same procedure?               How much is the appeal limit?
                                                                             ↓                                                 ↓
                                                                    Rep Agrees?                             May I have the
                                                                 ↙                     ↘                       claim# & call ref#?
                                                            Yes                         No
                                                          ↙                                   ↘
                                        What is the TAT                    What is fax# or Appeal
                                        for reprocessing?                 address to send the appeal?
                                                     ↓                                                 ↓
                                          May I have the                 How much is the appeal 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 claim is denied as non-covered charges under the patient plan as the provider is out of network then click on the link to follow the provider's out-of-network scenario.
• If the claim is denied as non-covered charges under the patient plan as DX or ICD-10 code is non-covered then it should be sent to the coding team for alternative diagnosis code.
• If the coding team provides an alternative code then update it and resubmit a corrected claim.
• If the coding team does not provide an alternative code then bill the claim to the secondary or consecutive payer if available or else release it to the patient.
• If the claim is denied as non-covered charges under the patient plan for other reasons then bill the claim to the secondary or consecutive payer if available or else release it to the patient.
• Before billing the claim to a Secondary or Consecutive payer, need to verify the eligibility of the patient for the secondary or consecutive payer.
• To verify the eligibility of secondary or consecutive payers, check the payer website if access is available or else call the insurance.
• If no other payer is active or available on DOS then release the claim to the patient.
• If the claim is denied as non-covered charges as per the provider contract and if payment is received in the payment history and the rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
• If the claim is denied as non-covered charges as per the provider contract and if the payment is received in the payment history but the rep denies to reprocess the claim and asks to send an appeal then submit an appeal to insurance.
• If the claim is denied as non-covered charges as per the provider contract and if the payment has not been received in the payment history then you can either submit an appeal or write off the claim. So work as per your client's instructions.
• Non-covered as per provider plan denial cannot always have the CPT issue or may differ, so follow the scenario tool as per denial reason.
• Click here if this denial occurs from MISSISSIPPI MEDICAID
  
• 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:

*

Reason for non covered:

* Non covered under patient plan Non covered under provider contract

Reason for non covered under patient plan:

* DX or ICD-10 not covered Other Reason

Reason for non covered under provider contract:

* CPT not covered under provider contract Other Reason

Specify Reason:

*

Time frame for corrected claim:

*

Did payment receive for same CPT with same provider from same insurance:

* Yes No

Rep agrees to reprocess:

* Yes No

TAT for Reprocessing:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Appeal Limit:

*

Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Resubmitted the claim Claim released to patient Need client assistance Need coding assistance Need to submit an appeal Appeal sent



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