How to wok on denial code - 45
45: Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
CO-45:
- As the description states, this denial occurs when the charge/CPT exceeds the fee schedule or maximum allowed amount.
- Fee schedule - It defines how much amount a CPT must get paid.
- Mostly the amount which is denied for CO-45 is the provider adjustment amount but it differs based on the scenarios. Below are the scenarios where CO-45 denial occurs and you can follow the mentioned steps to work on each scenario.
1. When the claim is processed & paid OR the claim is processed and applied towards patient responsibility (Deductible, coinsurance, and copayment).
- In this scenario, the amount which is denied for CO-45 is the adjustment amount. You can simply adjust this amount if have the authority.
- In this scenario, you can simply ignore the CO-45 denial and work on other denials to resolve the claim.
3. When the claim is denied and there is no other denial except CO-45.
- In this scenario, you will need to call the insurance and confirm the exact reason for the denial and work accordingly. (Do not assume that this is an adjustment amount)
PR-45:
- Sometimes, you will see PR-45 denial instead of CO-45 denial. You can still follow the above scenarios to work on PR-45 but the amount which is denied for PR-45 is the patient's responsibility.
- Do not bill the PR-45 amount to the patient directly. Get the confirmation from your client and work accordingly.
- It mostly occurs when the provider is out of network.
Thanks for your support
ReplyDeletebest work done appreciated
DeleteThank You!
Delete23 : The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)
ReplyDelete45 : Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. Usage: This adjustment amount cannot equal the total service or claim charge amount; and must not duplicate provider adjustment amounts (payments and contractual reductions) that have resulted from prior payer(s) adjudication. (Use only with Group Codes PR or CO depending upon liability)
charge exceeds fee schedule
ReplyDeleteHI ,Anthem payer denied the claim as non covered charges & per remark code claim was denied as he services billed are considered Not Covered or Non-Covered (NC).Kindly help me with this
ReplyDeleteYou will need to find out the exact reason for this denial. Please follow the below scenario to work on this denial,
Deletehttps://www.arlearningonline.com/2019/11/96-non-covered-charges.html
Cigna has processed the claim towards co-pay $1.29 on a claim with charge amount $1343 and as per Cigna this is only charge that is allowed as per the providers contract. Can we still adjust the remaining amount ?
ReplyDeleteThis information does not look correct. You should ask the insurance rep for more details. You may also check provider payment history if have access. It will let you know how much amount was paid previously on the same CPT for the same provider. Based on this, you can cross-question the insurance rep.
Deleterecoupment
ReplyDeleteHi we got denial for CO 45 charges exceed fee schedule after having conversation with representative said Kindly submit a dispute with your fee schedule so that the claim will be reviewed. so i asked We have different fee schedule based on the contract. And the charge that you have billed exceeded the allowable amount
ReplyDeleteafter this dont understand what to do kindly advise
Is any payment received on the claim that has a denial CO-45? And Is this denial received from primary or secondary insurance?
DeleteIf the denial is received from primary insurance and no payment is received then you can ask the rep that there is no payment received on the claim, please provide the exact denial reason.