8: The procedure code is inconsistent with the provider type/specialty (taxonomy)
On Call Scenario:
Claim denied as the procedure code is
inconsistent with provider type/specialty
↓
May I get the denial date?
↓
What is the exact reason for denial?
↙ ↘
Provider specialty is not Taxonomy code is missing
allowed to perform this service in the claim form
↓ ↓
Check the provider specialty At which box# on claim form
on NPPES Website taxonomy code is missing?
(Click here to visit NPPES website & ↓
Just enter rendering provider's NPI Check the claim form if
in NPI Number section and click on taxonomy code is available or not
'Search' Button. you will get provider ↙ ↘
specialty under 'Primary Taxonomy' Yes No
Section) ↓ ↓
↓ Can you please reprocess May I have the
Verify specialty with CPT the claim as information claim# & Call ref#?
↙ ↘ available on claim form?
Different Same ↓
↓ ↓ Rep agrees?
May I have the Can you please ↓ ↘
claim# & Call Ref#? reprocess the claim Yes No
as provider specialty ↓ ↘
Claim denied as the procedure code is
inconsistent with provider type/specialty
↓
May I get the denial date?
↓
What is the exact reason for denial?
↙ ↘
Provider specialty is not Taxonomy code is missing
allowed to perform this service in the claim form
↓ ↓
Check the provider specialty At which box# on claim form
on NPPES Website taxonomy code is missing?
(Click here to visit NPPES website & ↓
Just enter rendering provider's NPI Check the claim form if
in NPI Number section and click on taxonomy code is available or not
'Search' Button. you will get provider ↙ ↘
specialty under 'Primary Taxonomy' Yes No
Section) ↓ ↓
↓ Can you please reprocess May I have the
Verify specialty with CPT the claim as information claim# & Call ref#?
↙ ↘ available on claim form?
Different Same ↓
↓ ↓ Rep agrees?
May I have the Can you please ↓ ↘
claim# & Call Ref#? reprocess the claim Yes No
as provider specialty ↓ ↘
is same as CPT? ↓ May I have the claim#
↘ ↓ & call ref#?
What is the TAT
for reprocessing?
↓
May I have the claim#
& call ref#?
Important Note:
What is the TAT
for reprocessing?
↓
May I have the claim#
& call ref#?
Important Note:
- In CMS 1500 form, the rendering provider's taxonomy code is available in box# 24J above NPI and the billing provider's taxonomy code is available in box# 33b.
- When the taxonomy code is available in CMS 1500 and the rep is still not able to find it from their end then resubmit the claim again, information may be missing due to some error.
- When the taxonomy code is not available on the claim form then resubmit the claim to check taxonomy code still going on the claim form or not. If it is still missing then inform the same client.
i have Medicaid in the secondary and denied for same reason what can be the next step
ReplyDeleteCheck the taxonomy code available in the claim form or not at box# 24J and 33b. If the claim is crossed over by Medicare to Medicaid. Then you can simply resubmit the claim because the taxonomy code is sometimes missing on the crossed-over claim.
DeleteI have already resubmitted claim with claim form now claim denied for same reason
ReplyDeleteAfter resubmitting the claim, did you check the taxonomy code is updated on the new claim form or not?
DeleteIf you can see the taxonomy code on the claim form then you can contact the insurance and clarify the denial reason and if it is still not updated then you can escalate this issue to your client.
How to verify CPT speciality with taxonomy
ReplyDeleteYou can visit the below website to find the specialty of a provider based on the taxonomy code. This will help you to speculate CPT specialty.
Deletehttps://www.findacode.com/tools/taxonomy-codes.html
what should be the next steps if taxonomy code is not available? or if it, then rep does not agree to reprocess, can I ask what's the tfl to send appeal?
ReplyDeleteWe don't think that appealing to such a claim will work instead you can find a way to update the correct taxonomy on the claim form or if the correct taxonomy is available then resubmitting the claim. If still receive the same denial then confirm the issue with the rep and inform the client to get the resolution. You can follow the below steps as per the requirement,
DeleteIf the taxonomy code is not available on the claim form then resubmit the claim to check taxonomy code is still getting billed on the claim form or not. If it is still missing then inform the same client.
If the taxonomy code is available in CMS 1500 and the rep is still not able to find it from their end then resubmit the claim again, information may be missing due to some error.