50: These are non-covered services because this is not deemed a 'medical necessity' by the payer
On Call Scenario:
Claim denied as medically not necessity
↓
May I get the denial date?
Claim denied as medically not necessity
↓
May I get the denial date?
↓
What is the reason for medically not necessity?
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Check patient payment history if the same
DX code paid with same CPT
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to
payment received for same CPT & DX? send corrected claim?
↓ ↓
What is the TAT for reprocessing? What is the Fax# or Mailing
↓ address to send an appeal?
May I have the claim# & call ref#? ↓
How much is the time limit
to send an appeal?
↓
May I have the claim# & call ref#?
Important Note:
Check patient payment history if the same
DX code paid with same CPT
↙ ↘
Yes No
↓ ↓
Can you please reprocess the claim as What is the time limit to
payment received for same CPT & DX? send corrected claim?
↓ ↓
What is the TAT for reprocessing? What is the Fax# or Mailing
↓ address to send an appeal?
May I have the claim# & call ref#? ↓
How much is the time limit
to send an appeal?
↓
May I have the claim# & call ref#?
Important Note:
- This denial should be assigned to the coding team to review and provide the correct dx code and once a response is received with the correct dx details then send the corrected claim to insurance by updating the correct dx code even if the time limit to send the correct claim is crossed.
- If the coding team states that the dx code is correct 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 appeal, or else write off the claim if the time limit is crossed.
- Sometimes the client wants us to send the appeal even if the time limit is crossed, so work accordingly.
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:
Reason for medically not necessity:
Has payment found for the same CPT with same diagnosis code in the patient payment history?:
What Information is Available?:
TAT for Reprocessing:
Corrected Claim Time Frame:
Mode of appeal:
Fax Number:
Mailing Address:
Website Link:
Appeal Limit:
Additional Comment:
Claim Number:
Call Reference#
Action:
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ReplyDeletecould you please explain what is medically not necessity means??
ReplyDeleteIt means that the treatment or the service performed on the patient was not required medically. There could be a coding issue that you can verify from the coding team.
DeleteCPT 64495 with LT modifier ,medicare denied for medical necessity , i try to appending KX modifier still same denied ,kindly give me the suggestion
ReplyDeleteCan you please let us know the other cpts billed along with this cpt and the dx codes billed with this cpt?
DeleteIf received CO-50 with remark code M25 (The information furnished does not substantiate the need for this level of service), in this particular remarck, May I know exact follow. please guide me.
ReplyDeleteYou can follow the above scenario. Sometimes, the coding team confirms that the service is coded correctly then you can submit an appeal with all the appropriate documents that prove that it meets the medical necessity.
DeleteGreat Work
ReplyDeleteThanks!
DeleteCan you please let us know if medicare denied for co 50 then how can we resolve? Is there any different steps?
ReplyDeleteYou can assign the claim to the coding team to check if there is any coding issue that can be resolved by changing the code. If yes then update the required code and resubmit the claim.
DeleteIf there is no alternate code and the coding is correct then you can send an appeal along with the documents that prove the given service is medically necessity.
And also please elaborate if ABN on file then what steps needed or ABN not on file then what are the steps to be taken?
ReplyDeleteThere may be a chance that even after sending an appeal along with the proper documents, the claim will not get paid. Then if the ABN is signed by the patient then you can bill the claim to the patient but if it is not signed by the patient then you will need to adjust the claim.
DeleteCan someone please confirm this. In all denial scenarios note stated that if the time limit to send the correct claim is crossed. I f we crossed the TFL for corrected claim insurance won't pay for us right? Then why submitting the claim to Insurance.
ReplyDelete