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
the maximum allowance for a
specific time period
↓
May I get the denial date?
↓
May I know the reimbursement guideline of the CPT?
↓
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:
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?:
TAT for Reprocessing:
What Information is Available?:
Corrected Claim Time Frame:
Mode of appeal:
Fax Number:
Website Link:
Mailing Address:
Appeal Limit:
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
Thanks it was much needed
ReplyDeleteThank you.
DeleteThis also happens to Hospitalists that treat the patient in-patient. If one specialty bills a CPT and then another specialty bills the same admit/followup code they sometimes deny. Simply calling the insurance company and advising them that the 2 providers that billed the same code on this date are of differently specialties. They will send the claim back for reprocessing and then pay the claim.
ReplyDeleteThanks for sharing this information.
DeleteThank you for supporting.
ReplyDeleteThanks
ReplyDeleteIs there any way where, I can get details for frequency of any CPT code?
ReplyDeleteYou can try to find out the frequency of a CPT on cms.gov website
DeleteSuppose cpt is allowed to bill once per 90days last time it was billed by provider not from our group or facility and we have received 151 denial is it still a correct denial
ReplyDeleteNo, it is incorrect. You can make a call and ask the rep to reprocess the claim.
DeleteIf it is a different group also the denial is correct insurance will not pay when the CPT code exceeds its frequency
DeleteIf the CPT is allowed to pay once in 90 days and one of the provider already billed it in the last 90 days and if it is billed again within 90 days then it will get denied. Yes, it is correct. I think our answer was wrong previously as we did not understand your question.
DeleteBut, how is it correct if the claim is billed from a different group? Can you please explain? Is this guideline of once in 90 days under patient policy or what?
My question is supposing a particular cpt code is allowed once per 30days provider A has billed that cpt. Now same cpt is billed by provider b within 30days got denial as co 151.Provider A and B are not into the same group. Now is it a correct denial or not?
DeleteNo its an incorrect denial ask for reprocess. because both the providers are from different group.
DeleteActually I have received this denial from Medicare there is two unit billed for that procedure. Is it possible when we bill more units same Daniel came.
ReplyDeleteIt may be possible but sometimes it may get paid for one unit and denied for another. So, you will receive a denial and payment for the same claim.
DeleteI am working on labs billing and billing team wrongly billed the same claim with same CPT (s) on same DOS and on Same Date and in result both claims got denied due to the denial code 151 and my question is what should we do now to get payment of such claims
ReplyDeleteYou can void or delete one CPT line and send a corrected claim with a denied claim number by selecting only one CPT.
DeleteBut the payer is Medicare and Medicare don't accept the corrected claim
DeleteMedicare accept the correct claim add condition code and resubmit...if Claim rejected do a appeal claim will get paid
DeleteI have already adjusted duplicate claim and resubmitted the other one but still am confused they are going to paid or denied again let's see because Medicare takes turnaround time about 10 to 15 days maximum.
ReplyDeleteMost probably, it will get denied as a duplicate. For Medicare, you need to void the claim first by resubmitting the claim with resubmission code 8. It is the same as sending a corrected claim but you need to select code 8 instead of 7.
DeleteThen, you will need to check the status if it will be voided or not. Once it is voided then you can resubmit the claim and it will be considered as a new claim.
You can also connect with a Medicare rep to confirm these details and get the more available steps.