151: Payment adjusted because the payer deems the information submitted does not support this many/frequency of services

On Call Scenario:

                                                     Claim denied as CPT has reached
                                                         the maximum allowance for a

                                                                 specific time period
                                                                               ↓
                                                            May I get the denial date?
                                                                               ↓
                                        May I know the reimbursement guideline of the CPT?

                                     (For example, CPT is allowed once a day, twice a day etc)

                                                                               ↓

                                    Based on the above guideline identify whether insurance

                                                 has denied the claim correctly or not.

                            (For example, if the insurance rep confirms that CPT is allowed

                               to pay once a day then you need to check in your system if the

                            same CPT code has already been paid on the same day or not. If

                           the CPT is already paid on the same day then the denial is correct

                               and if you are not able to find the same CPT on the same day

                                                            then the denial is incorrect.)

                                                       ↙                                                ↘

                           Denied Correctly                                                     Denied Incorrectly

                                       ↓                                                                                 ↓

                      What is the time limit to                                          Could you please send the

                        send corrected claim?                                           claim back for reprocessing

                                       ↓                                                           since the CPT has not met the 

                  What is the Fax# or Mailing                                          maximum allowance?

                   address to send an appeal?                                                            ↓

                                       ↓                                                                     What is the TAT

                   How much is the time limit                                               for reprocessing?

                         to send an appeal?                                                                   ↓

                                       ↓                                                                      May I have the

                      May I have the claim#                                                  claim# & call ref#?

                              & call ref#?

Important Note:

• If you are not able to find CPT in the system but the insurance rep confirms that the same CPT is already paid as per their records then there is a possibility that that particular charge is not posted in your system or may be billed by another doctor of the same facility. In such a scenario, ask for the details of that CPT with the doctor's name and mention the same in your notes and consider it under denied correctly.
• If the claim is denied correctly then follow your client update to take the action. An action could be sending an appeal or writing off the claim.

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:

*

What is the allowed frequency?:

*

Is claim denied correctly?:

* Yes No

TAT for Reprocessing:

*

What Information is Available?:

* Corrected Claim Time Frame Appeal Information Corrected Claim Time Frame and Appeal Information None

Corrected Claim Time Frame:

*

Mode of appeal:

* Fax Mail Website

Fax Number:

*

Website Link:

*

Mailing Address:

*

Appeal Limit:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Need coding assistance Updated correct modifier and resubmitted the claim Updated correct CPT and resubmitted the claim Updated correct DX and resubmitted the claim Adjust off the claim Need client assistance Need to send an appeal Need to allow time Appeal Sent



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