23: The impact of prior payer(s) adjudication including payments and/or adjustment
Denial Occurrence:
- This denial occurs when primary insurance already pays more or an equal amount to the secondary allowable amount.
- The Below examples will help to understand when and how secondary insurance pays or denies the CPT for denial 23.
- Example 1: A CPT with a billed amount of $90.00 is allowed by primary insurance for $20.00, paid for $16.00 and PTR is $4.00 as coinsurance. When secondary insurance processes the same claim then as per secondary insurance the same CPT is allowed for $20.00, since primary insurance has already paid $16.00 then it pays the remaining $4.00.
- Example 2: A CPT with a billed amount of $120.00 is allowed by primary insurance for $30.00, paid for $24.00 and PTR is $6.00 as coinsurance. When secondary insurance processes the same claim then as per secondary insurance the same CPT is allowed for $28.00, since primary insurance has already paid $24.00 then it pays the $4.00 and denies the remaining $2.00 from coinsurance for denial 23.
- Example 3: A CPT with a billed amount of $100.00 is allowed by primary insurance for $25.00, paid for $20.00 and PTR is $5.00 as coinsurance. When secondary insurance processes the same claim then as per secondary insurance the same CPT is allowed for $20.00 and it finds that the primary insurance has already paid $20.00 then it denies the balance amount for denial 23.
- If denial 23 is received from primary insurance and there is no payment then need to call the insurance and confirm the denial reason.
On Call Scenario:
Claim denied as primary paid more
than secondary allowed amount
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May I get the denial date?
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What is the allowed amount?
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Check in system, how much amount
is paid by primary insurance?
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Is primary paid amount greater than or
equals to secondary allowed amount?
↙ ↘
Yes No
↓ ↓
May I have the Could you please reprocess the claim
claim# and Call ref#? as primary PA is less than secondary AA?
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What is the TAT for reprocessing?
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May I have the claim# and Call ref#?
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Important Notes & Actions:
Claim denied as primary paid more
than secondary allowed amount
↓
May I get the denial date?
↓
What is the allowed amount?
↓
Check in system, how much amount
is paid by primary insurance?
↓
Is primary paid amount greater than or
equals to secondary allowed amount?
↙ ↘
Yes No
↓ ↓
May I have the Could you please reprocess the claim
claim# and Call ref#? as primary PA is less than secondary AA?
↓
What is the TAT for reprocessing?
↓
May I have the claim# and Call ref#?
\
Important Notes & Actions:
- Please take action as per your process update. Below actions can be different from your process update.
- If the primary paid amount is more than or equal to the secondary allowed amount then write off the balance.
- If the primary paid amount is less than the secondary allowed amount and rep agrees to reprocess the claim then set the follow-up for the TAT provided by the rep.
- 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:
What is the allowed amount of secondary insurance?:
What is the paid amount of primary insurance?:
Is primary paid amount greater than or equals to secondary allowed amount?:
TAT for Reprocessing:
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
Note: We are not saving any of your inputs or notes in the backend
where from we can get information how much secondary allowed amount?
ReplyDeleteMost of the time, it is available on on EOB of secondary insurance. If it is not available then you can utilize payer portal if have access. Or else you need to confirm on call.
Deletehow can we found that the primary paid more then the secondary allowed amount i have received a denial from BCBX TX , Medicare is primary total charge amount is $215 and Medicaid paid 88.17 and co insurance amount is 22.49 but claim is still denied.
ReplyDeleteIf you have received a denial from secondary insurance - BCBS TX then you need to know the allowed amount of BCBS TX. You can find it on EOB or Availity website then check whether allowed amount of BCBS TX is less than or equal to paid amount of $88.17. If it is less than or equal then this denial is correct and no amount will get paid. If it is greater than medicare paid amount then the difference between allowed amount of BCBS TX and paid amount of Medicare should be made by BCBS TX. You will need to call the BCBS TX and ask to reprocess the claim.
DeleteWrong answer
DeleteHi, thank you for your very helpful website! If the primary payer's allowed amount is greater than the secondary's, and there is a patient responsibility after the primary payer paid, can we collect this patient responsibility from the patient?
ReplyDeleteNo, it cannot be billed to the patient. It must be written off.
DeleteMedicare processed the claim charge 120$ and allowed 100 and paid 80$ and left co ins of $20 uhc processed as secondary and allowed 100 but 80$ as oa 23 left same co ins of 20 as pr 2 should i adjust the claim of bill patient
ReplyDeleteBill it to the patient.
DeleteWhy may i know the reason
DeleteBecause primary and secondary both allowed the claim for $100.00 and primary already paid $80.00 out of $100.00. Now secondary is responsible to process or pay $20.00 and as mentioned secondary already applied it towards coinsurance. So, it must be sent to tertiary insurance if available or patient.
DeleteOA23 denial is for $80.00 that already paid by primary insurance. Do not consider it for the entire claim.
secondary partially paid the claim and denied the CPT code 97140 due to OA23.while CPT CODE 98942 paid allowed amount is $56.73 and paid $11.35
ReplyDeleteJust check for how much amount CPT 97140 is allowed by secondary insurance. If the secondary allowed amount is less than the primary paid amount for CPT 97140 then it is denied correctly.
DeleteDo we need to Consider Primary Ins Allowed amount or paid amount? if secondary insurance say they don't consider contractual adjustment b/w primary ins and provider and they will only pay if there benefit is more than primary ins benefit in that case do we need consider the difference between paid and secondary allowed or Primary allowed - secondary allowed?
ReplyDeletePlease use the formula: (Allowed amount of secondary insurance - Paid amount of primary insurance). If the result is positive then this denial is incorrect and the result amount needs to be paid by secondary insurance. If the result is negative or 0 then this denial is correct.
Deletehi
ReplyDeleteIf primary insurance BCBS processed whole amount as deductible and secondary medicare denied for OA-23 ?
The denial OA-23 is not correct here. You need to call the insurance and verify the correct reason for denial.
DeleteIf the patients does not have any secondary insurance… so what would be the next step …?
ReplyDeleteHas primary insurance paid the claim? or else if the claim is denied by the primary insurance for denial code 23 without any payment then you would need to call the insurance and verify the correct reason for denial.
DeleteWhat if there's no payment but this is the denial, how to correct please?
ReplyDeleteIf this denial occurs without any payment then you will need to call the insurance and confirm the correct reason for denial.
DeleteAfter account is write off, does account balance moves into Credit or Debit. Please explain with an example.
ReplyDeleteSuppose there is a claim for $100.00 and it is processed by insurance and allowed & paid for $20.00 then it should be posted with the below amount
DeleteAllowed - $20.00
Paid - $20.00
Coinsurance - $0.00
Deductible - $0.00
Copayment - $0.00
Adjustment - $80.00
With the above posting, the balance amount will become 0. But, if there is any incorrect posting on adjustment or paid amount then the account will move into credit or debit.
For example, if by mistake the adjustment is posted as $90.00 then the claim balance will be in credit for -$10.00 and if the adjustment amount is posted as $75.00 then the claim balance will be in debit for $5.00.
If you find any account in credit then always check whether the posting is done correctly or not.
Note: It is not always the posting issue. Sometimes, insurance made the payment twice in an error that can also move the account in credit. In such a case, payment needs to be refunded to the insurance.
There are instances that this denial OA23 is from the primary insurance and the account does not have any secondary insurance. Can you explain why this scenario exists? And what will be the possible for the claim be processed and paid?
ReplyDelete