AR Scenario - Click on Specific Scenario
We have added a tool to prepare notes in the below highlighted scenarios (in bold). You will find this tool at the bottom of each scenario page. We will keep adding this tool for all the scenarios in the coming days. Please do share your feedback and suggestions to improve this tool.
- No Claim on File
- Claim in process
- Claim is approved to pay
- Claim paid
- Claim paid & applied towards offset
- Claim paid to patient
- Claim applied towards Deductible
- Claim denied as patient cannot be identified
- Claim denied as Coverage Terminated
- Claim denied as the time limit for filing has expired
- Claim denied as authorization absent or missing
- Claim denied as referral is absent or missing
- Claim denied as maximum benefit exhausted/reached
- Claim denied as non covered charges
- Claim denied as non covered charges as provider is out of network
- Claim denied as additional information requested from patient
- Claim denied as additional information requested from provider
- Claim denied as medical records requested
- Claim denied as Duplicate
- Claim denied as patient enrolled in hospice
- Claim denied as procedure code inconsistent with the modifier used
- Claim denied for invalid modifier on date of service
- Claim denied as diagnosis code is inconsistent with the procedure
- Claim denied as diagnosis code is invalid for date of service
- Claim denied as Procedure code was invalid on the date of service
- Claim denied as referring provider is not eligible to refer the service billed
- Claim denied for primary EOB
- Claim denied as other payer is primary
- Claim denied as Secondary payment cannot be considered without the identity of or payment information from the primary payer
- Claim denied as claim not covered by this payer
- Claim paid directly to provider under Capitation contract/Claim denied as patient covered under capitation or managed care plan
- Claim denied for invalid place of service
- Claim denied as primary paid more than secondary allowed amount
- Claim denied as medically not necessity
- Claim denied as This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier
- Claim denied as This injury/illness is covered by the liability carrier
- Claim denied as This injury/illness is the liability of the no-fault carrier/Auto insurance
- Claim denied as Bundle/Inclusive
- Claim denied as Globally inclusive to Surgery
- Claim denied as procedure combination is not compatible with another procedure
- Claim denied as procedure code is not paid separately
- Claim denied as rendering provider is not eligible to perform the service billed
- Claim denied as the procedure code is inconsistent with provider type/specialty
- Claim denied as routine services not covered
- Claim denied as This provider was not certified/eligible to be paid for this procedure/service on this date of service
- Claim denied as pre-existing condition not covered
- Claim denied as Procedure code is inconsistent with patient's gender
- Claim denied as Procedure code is inconsistent with patient's age
- Claim denied as diagnosis code is inconsistent with patient's gender
- Claim denied as diagnosis code is inconsistent with patient's age
- Claim denied for invalid or missing NDC Code
- Claim denied for invalid or missing CLIA Number
- Claim denied for New patient/Established patient criteria not met
- Claim denied as Prior processing information appears incorrect
- Claim denied as CPT has reached the maximum allowance for a specific time period
- Claim denied as the date of death precedes the date of service
- Claim denied as Procedure/treatment/drug is deemed experimental/investigational by the payer
- Claim denied as Revenue code and Procedure code do not match
- Claim denied as Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement
- Claim denied as Payer deems the information submitted does not support this level of service
We are a laboratory. I have a problem in our billing department. We have several CPT CODES. Some need preauthorization and some don't. We are getting denied for preauthorization, so the billing department is only billing the codes that don't need preauthorization. I have nbeen doing this a long time and I was taught that you still bill the CPT CODES that you were denied preauthorization. Am I correct or am I wrong? Pleas eadvise.
ReplyDeleteThey can definitely bill codes without authorization. However, most payors will deny the entire claim--so your billers then have to submit a corrected claim with the authorized codes only. This delays payment and costs your billers time that could be used to better work the rest of your AR.
DeleteYes you can bill the claim without auth. But some insurance ask for auth# for particular codes. And as per their guidelines authorization is mandatory for particular codes and it may depend on patient's plan as well.
DeleteYes, you can still resubmit the CPT codes and wait for the response, just to make sure it would require preauthorization. If you have already listed down the CPT codes where preauthorization is necessary then it would be good to notify your providers to take preauthorization before rendering such services in future.
ReplyDeleteRight!
Deletewhich payer are you trying to bill, In lab or in any process being participated with Payer is important, so you might need to check if your provider is participated with payer or not, if you are participated then still few lines request Auth, so you need to ask a list of CPTs from payer or your relation ship manager for that list.
ReplyDeleteThank you Ankita for sharing information.
DeleteI usually think of informative content as dull but necessary for learning. Interesting informational articles like this are rare. This material is informational without being boring and intimidating. Thank you.
ReplyDeleteHospice Billing Services
Thank you Noah. That's so good to hear!
DeleteYou can also help us with the denial codes and their reasons and action to be taken on them ..
DeletePlease follow below link,
Deletehttps://www.arlearningonline.com/p/denial.html
what is the difference between Co-96 and Co-204?
ReplyDeleteCO-204 states services are not covered under patient plan whereas CO-96 does not give the same clarity. It is necessary to check the remark code to find out the exact denial reason in case of CO-96 denial code. But, sometimes even remark does not provide the exact reason and need to make a call to find out the correct reason. Mostly when claim denied for CO-96 then reasons could be coding issue, services not covered under patient plan or services not covered under provider contract.
DeleteEven when the claim denied for CO-204, always check the remark code. Sometimes, services are non covered due to diagnosis code issue that can be resolved by coding alternate diagnosis code.
Please add more scenarios like for urgent care we don't need authorisation and in that case when we call to rep and ask for reprocess the claim as no auth is required ..
DeleteAuthorization scenario is already available in the above list and it covers the steps that you have mentioned.
DeleteDo all providers need to get prior authorization? or only the specialists on special treatments and medications? Does my primary care provider need prior authorization to see me for routine checkup as well?
ReplyDeleteNot all services require prior authorization but there are certain procedures, tests and medications that require authorization. Healthcare providers are responsible to obtain the prior authorization from insurance to get the reimbursement of the treatment that they are going to perform. Yes, specialists are responsible to obtain prior authorization. But, there could be a situation where PCP will act as specialist and needs to render certain procedures, tests or medications that do require prior authorization. In such cases, PCP will be responsible to obtain the prior authorization.
DeleteFor Authorization there is one more word which is known as pre-certification.
DeleteSo for this type of case we have to go for no Authorization denial..
Yes, you are correct. Pre-certification, pre-authorization, prior authorization - all these are same. so, please follow no authorization denial.
DeleteCip
ReplyDeletehi ,
ReplyDeleteis there any portal or anyone who can give training of ar denial
No, currently we do not have anyone to provide the training. But will recommend you to join the Medical billing company where you will get the training and practical knowledge.
DeleteIf you really what training on Medical billing , it is best to join Medical billing company and if you want i can help you in joining my company as Referral (Fresher) . the company is in mumbai . they train fresher for 1 month with deep knowledge .
Deletecompany name?
DeletePlease follow below link,
Deletehttps://www.arlearningonline.com/p/denial.html
I need ICD 10 denial book
ReplyDeletePlease check online to find the ICD-10 book with best price.
DeleteNational Provider Identifie
ReplyDeleteNational Provider Identifier > anyone's help us how we that resolve that Denied 208
ReplyDeleteIt's a credentialing denial, please follow below scenario to work and resolve it.
Deletehttps://www.arlearningonline.com/2019/12/this-provider-was-not-certifiedeligible.html
Hello, Can any one tell me about the denial reason CO-151 ,What is proper method to resolved this denial?
ReplyDeleteHello,
DeleteWe have added a new post on denial code 151. Please go through it,
https://www.arlearningonline.com/2022/06/151-payment-adjusted-because-payer.html
hahhahahahah
ReplyDeleteHi, Can you please Explain IPA, And how to handle if we get these type of denial...?
ReplyDeleteAssuming that you have received a denial from payer stating the claim needs to be billed to IPA. If this is the scenario then you need to get the IPA details such as IPA name, mailing address or payer ID. Then, bill the claim to IPA.
DeleteReason for IPA denial - Sometimes, payers have a contractual agreement with IPA in which the IPA pays for the claims at the payer's contracted rates. So, claim must be billed to IPA.
Please let us know if our assumption is incorrect and write us back by elaborating the question.
You have to call to concerned IPA ( Independent physician associations ) and ask about weather they received the claim or not if yes ask about claim status. If they say Health plan is responsible for this claim to be processed. Get reference number and call to health plan and tell them that As per IPA you are responsible and they will get your claim processed.
DeleteThank you... We are doing the same when the claim denied for IPA responsibility. But I want to know what is IPA and Who is IPA. Please explain.
DeleteAs mentioned in my previous comment IPA is actually Independent physician associations which are working independently. They process the claims by themselves and pay by themselves. They are not attached with other insurance companies. If a patient visits IPA they will be responsible as per contract or patient's plan.
DeleteAmazing tool, even a layperson can follow up with assistance
ReplyDeletei am a fresher and how to start analysis encounters
ReplyDeletePlease visit the below link and follow the steps as mentioned,
Deletehttps://www.arlearningonline.com/2021/06/ar-analyst-process.html
can anyone guide me claim denied stating plan procedure not followed even cpt is correctly billed
ReplyDeleteThis denial does not provide the exact reason, please check if any remark is available that can provide more details. In case no remark is available then you will have to make a call and ask the reason.
Deletecan anyone tell me what's the frequency limit of CPT 80061 as per BCBS NC?
ReplyDeleteCan you plz tell claim denied as after review the patient claim history....!!!!?
ReplyDeleteIt seems that patient was performed with certain services in the history which proves that the current service cannot be performed. You may consider this denial as medically not necessity and assign the claim to coding for clarification. But, before that you must gather additional details from insurance rep that is, what is the exact information they reviewed on claim history which led to denial of this claim? This information will be helpful for coding team.
DeleteTHANK YOU SO MUCH !
DeleteThis denial is Basically for medical records ins needs medical records to process the claims further
DeleteThank You
DeleteWhat is the reason claim got denied as Column I/ Column II Procedures !!!
ReplyDeleteIt is bundling denial. You should follow bundle denial scenario to work on such claims.
Deletewhat does denial CO - 13 mean? and how to fix this? thank you
ReplyDeleteWe have added as post on denied code - 13,
Deletehttps://www.arlearningonline.com/2022/10/13-date-of-death-precedes-date-of.html
Hi,
ReplyDeletekindly give is knowledge about rejection like A0, A2, P4, M8
Can you please share the description of all these codes?
Deletewhat about "Claim paid & applied towards capitation"
ReplyDeleteIt is available in the above list,
Deletehttps://www.arlearningonline.com/2019/12/24-charges-are-covered-under-capitation.html
Hey all, please help in lab billing and creating panels, anybody knows pls ping
ReplyDeleteCan you please send us an email at contact@arlearningonline.com along with the specific questions that you have on lab billing?
DeleteMedicaid denied ( M76 ) RECIPIENT ENROLLED IN THE FAMILY PLANNING PROGRAM, could you please explain the solution
ReplyDeleteIt means that the patient is enrolled in the family planning program and the denied service is not covered under family planning program. So, it needs to be released to patient. But, in case of medicaid, you cannot release to patient. So, take the action as per your client update.
DeleteDo you have any scenarios for non voice Ar job
ReplyDeleteAll the above scenarios can be non voice, you can visit website to obtain status or sometimes you can resolve the account by analysis. Just go through with below post, it may help you to understand what or why are we saying this,
Deletehttps://www.arlearningonline.com/2021/06/ar-analyst-process.html
do you have a scenario for procedure code incidental to primary procedure
ReplyDeleteIt is a Bundling denial and already listed in the above list,
ReplyDeletehttps://www.arlearningonline.com/2019/12/97-benefit-for-this-service-is-included.html
Patient cannot be identified as our insured. what does this meaning and how to solve?
ReplyDeleteIt means that the patient information is not available with insurance or else patient information is available but policy ID, name or DOB is incorrect. Follow the below post to find the solution,
Deletehttps://www.arlearningonline.com/2019/11/31-patient-cannot-be-identified-as-our.html
Thank you for your response.
DeleteWe do not offer coverage for this type of service or the patient is not enrolled in this portion of our benefit package.Can you please explain this remark code
ReplyDeleteThere are 2 statements in this remark. First statement "We do not offer coverage for this type of service", it states that the insurance does not cover the CPT code and second statement "the patient is not enrolled in this portion of our benefit package", it states that the CPT is not covered under the patient plan.
DeleteIt needs to be confirmed with the insurance rep which one is to be followed for this claim.
On second statement, claim can be submitted to secondary payer and if secondary insurance is not available then release to patient.
On first statement, it requires to confirm the reason - why is it not covered? and if needed send appeal.
You are required to code to the highest level of specificity. Can you explain this.
ReplyDeleteMost of the times, it is coding related issue but it is always better to confirm with insurance rep and once confirmed that it is coding related issue then assign to coding team.
ReplyDeleteIf this denial is from Medicare then you can follow below link for more details,
https://med.noridianmedicare.com/web/jeb/topics/claim-submission/reason-code-guidance/coding-to-the-highest-level-of-specificity
Can submit appeal bcoz you don't have direct contact with patient, submit appeal along with medical records, also check, auth denial coming from a specific payer or from every payers, basically auth deoends on patient plan,but some insurance have their own guidelines, they have ser of cpt codes which requires auth#,every service doesn't require auth, so you can request for that set of codes,
ReplyDeleteReally nice 👍 very helpful for me i m working as a fresher in Ar
ReplyDeleteClaim denied Referral absent Could you please explain how to resolve in UHC ... Thank you
ReplyDeleteYou can go through with the below referral scenario that will help you to resolve the claim,
Deletehttps://www.arlearningonline.com/2020/02/288-referral-absent.html
How we deal with scrub or you can say that rejection?
ReplyDeleteHow we deal with scrub or you can say that rejection?
DeleteFor both system rejection and clearing house rejection, you can find the rejection reason and based on the reason you can simply correct that and resubmit the claim.
Please let us know if there is any rejection reason where you find difficulties to understand or need help.
Claim denied as " The procedure(s) billed exceed the maximum frequency limitation allowed for this service based on the Health Plan's Reimbursement Rules." what wil do next step...? could you please explain..
ReplyDeletePlease follow below post,
Deletehttps://www.arlearningonline.com/2022/06/151-payment-adjusted-because-payer.html
IF ANYONE KNOW ABOUT DENIAL REASON FOR IME REPORT AND WHAT TO DO FOR THE DENIAL PLEASE FEEDBACK.
ReplyDeleteWhether Medicaid processes coinsurance or not ?
ReplyDeleteYes, Medicaid does. If Medicaid is denying any claim then check the denial reason for not processing coinsurance.
DeleteThank you for your response, i apology for question which i asked, what my question is if Medicaid is last payer then it process coinsurance.. can we send that coins to patient ?
DeleteYes, it can be billed to patient. But there are exempted group where patient billing is not allowed. So, it is better to get the confirmation from your client and work accordigly.
DeleteDenied for this reason Medically Unlikely Edit
ReplyDeleteCan you please provide the complete denial reason?
Deletehi were can i find payer id for SC prisma health senior care
ReplyDeletePayer Id for Prisma Health is 81040. But, it would be better if you make a call to insurance and confirm.
DeleteWhat denial is Co 115
ReplyDeleteCO 115: Procedure postponed, canceled, or delayed.
DeleteAs description states this denial occurs when procedure is postponed, canceled or delayed. There could be multiple reason for this denial. For example, when patient is taken to the operation room, doctor finds some other health issue that needs to be treated first. So, he/she postponed or canceled the treatment.
When coding this scenario, CPT must be billed with a specific modifier that indicates procedure is postponed, canceled or delayed. In absence of correct modifier, this denial occurs.
This is my question...
ReplyDeleteWhat if a claim is denied as the services rendered by a non participating provider and member's plan does not cover out of network services benefits and the plan type is HMO, so does the provider gets paid ?
ReplyDeleteInsurance will not pay this service as patient does not have out of network benefit. But, this is patient responsibility, provider can release the amount to patient and get it reimbursed.
DeleteIF CLAIM IS DENIED AS PROVIDER IS NON PAR FOR MEDICARE MANAGED CARE PLAN ,NEED TO APPEAL THE CLAIM WITH WOL (WAIVER OF LIABILITY ) TO GET CLAIM PAID WE DONT BILL PATIENT FOR NON PAR PROVIDER
DeleteYou may have the client specific update. In general, the above statements can be followed. But, you can ask your supervisor or client about this update. They will surely provide the reason.
DeleteDo you have any specific questions to invalid NPI
ReplyDeleteIf you are asking this question by checking EOB then you can make a call and there could be multiple possibilities for this denial but all will be related to credential denial. So, just follow below scenario.
Deletehttps://www.arlearningonline.com/2019/12/this-provider-was-not-certifiedeligible.html
If you have received this denial on call then you can probably ask which NPI is invalid. There are multiple NPIs on claim form. You can ask for the box# where the invalid NPI is mentioned and validate that on NPPES.
https://npiregistry.cms.hhs.gov/search
Most of the times, the NPI is valid and you will get the denial reason which is mentioned on above scenario link.
Hi, my name is Yaseen. I had a recent interview, and the interviewer asked me, What if one cpt pays and the other cpt is denied pre-authorization? I was scramble to tell this and confused, later I thought make a notes :
ReplyDelete1. We need to lookup what is the claim allowed amount
2. If paid cpt covers all allowed amounts, in that case we need to adjust denied cpt
3. If the paid cpt does not cover the allowed amount, we need to check in history whether the denied cpt previously paid or not. or else we will works as per authoration scenario.
Please do reply
Thanks
It is not necessary that all CPTs of a claim form will require Authorization. Same thing with your scenario, the CPT which is denied, may require authorization. So, you need to follow authorization scenario for denied CPT.
DeleteChecking the history of denied CPT is the good thing. Thanks for sharing this.
I was keep tracking up for your response, Thanks for that, and your doing great job, I recommend my colleague to visit this page.
ReplyDeleteThanks
Thank you.
DeleteClaim denied for surprise medical bill ??? can you plewase explain what should we do ?
ReplyDeleteThis denial states that the service is provided by out-of-network provider. You can follow below scenario to work on this,
Deletehttps://www.arlearningonline.com/2019/11/96-non-covered-charges-provider-is-out.html
Claim just denied " Not the Member's PCP "
ReplyDeleteCan you please explain this. Can you please suggest what I can do for further step
Thank youi
It seems like patient visited to PCP who is not assigned to him/her. But Please call the insurance and confirm whether it is correct or not.
DeleteIf it is correct then you can check patient plan. For HMO and POS, PCP visit is required and patient visited to PCP who is not assigned to patient then the claim can be billed to patient. If the plan is other than HMO or POS then you can ask rep to reprocess the claim.
Before releasing to patient just confirm with your client if it is allowed because there are some state guidelines where it is not allowed.
Thank you
DeleteHi can you please tell me, can IL Medicaid covers coinsurance amount from primary payer.
ReplyDeleteYes, They do cover coinsurance amount. But, it is also dependent on policy agreement.
DeleteThe initial visit is disallowed because it was billed on the same day how to solve this denial ?
ReplyDeleteIt seems that the same service is already billed on the same date of service and it is paid as well. You can verify that and if it is correct then the denial is correct, you can ask for coding help for correct CPT.
DeleteIf you are not able to find the same CPT paid on the same date of service then ask rep to reprocess the claim or else get the details if it was billed by any other provider.
As Medicaid stating " Recipient is QMB only " could you please explain what is QMB and further steps.
ReplyDeletePlease visit below link to know more about it,
Deletehttps://www.arlearningonline.com/2020/01/medicaid-qmb-slmb-qi-qdwi-program.html
If claim denied for AUTH retro AUTH is possible or not. Those insurance will give retro AUTH
DeleteIf the insurance reps confirm that it is still possible to obtain retro auth then you can ask for steps to obtain it. You will not directly get the retro auth on call, there are few steps that you will need to follow. You may require to submit few documents.
DeleteThank you
Deletenon cover denials need to call & get service is non covered as per patient plan or provider contract if rep said patient plan mean need to bill PT, provider contract mean need to write off. This is basic in medical flied But some insurance even not covering the basic 99204 office visit. And member has medical coverage to.one of ins rep stated inappropriate DX for the CPT billed. As per rep the dx F524 cannot billed as primary and suggested to submit a corrected claim with the dx R3129 billed as primary. Its the statement is correct. And what's the next step to move the claim and get the payment.
ReplyDeleteThe statement given by the rep could be correct. But validate it from your end by checking the medical records. If you are not a coder then assign the claim to coding team with this statement.
DeleteDo you have any link for Home Health. in home health denials are diff cant use this link for all scenario.
ReplyDeleteCurrently, there is no link but let us think about this to create a scenario on home health denials. Thanks for your comment!
Deleteyou have done a wonderful job, kudos to you.
ReplyDeleteThank you.
DeleteDo you have a scenario when claim denied for invalid revenue code/HCPC combination
ReplyDeleteYou can refer below scenario for this denial,
Deletehttps://www.arlearningonline.com/2022/12/199-revenue-code-and-procedure-code-do.html
Thanks. I admire your efforts. Love from Pakistan
ReplyDeleteThank you.
DeleteHi Team, Need clarification for the denial "DATE OF SERVICE OUTSIDE OF
ReplyDeleteAUTHORIZED DATES" Will it be considered as contractual obligation or patient will be responsible for the amount. Please clarify
It needs to be clarified by the insurance rep. There could be 2 possibilities,
Delete1. No Coverage
2. No Authorization
Based on the response that you will get on a call, you can take action.
Yes please explain and tell us like similar website other than www.arlearningonlime.com will be helpful in future if we get any some kind of issue in this website i hope it will not just simply future things give us some more website link where we can learn like this i am curious to know from your point.?
ReplyDeleteActually, I created this website 4 years ago because that time I did not find any website that was very helpful for AR learning.
DeleteNow, you can find a few websites on Google where you can see similar content. It's up to you, you can follow any of them whichever you find good to learn AR.
Its very good and useful to everyone
ReplyDeleteThank you!
DeleteCould you guys add denial scenario for CO-231 Mutually exclusive procedures
ReplyDeleteIt is same as bundle denial. So, you can follow the below scenario to work on this denial,
Deletehttps://www.arlearningonline.com/2019/12/97-benefit-for-this-service-is-included.html
Hi Guys, please can anyone help on this, is there any modifier for SNF ?
ReplyDeleteCan you please explain the scenario for which you need the modifier in SNF?
Delete
Deleteif the pt is enrolled in SNF we typically do not bill those claims in lab billing.
I was hoping there was a modifier that would identify the testing ordered is unrelated to the SNF
hi
ReplyDeleteHello Friends, Can anyone guide about the OIG audit for 81408 ? interms of check list please !
ReplyDeletePlease check the below link, it may be helpful for you.
Deletehttps://oig.hhs.gov/oas/reports/region9/92203010.asp#:~:text=How%20OIG%20Did%20This%20Audit,through%202021%20(audit%20period).
What is the Scenario if claim is processed as only Copay amount? please guide me.
ReplyDeleteYou can ask the below questions.
Delete1. May I have the processed date?
2. What is the Allowed Amount(AA)?
3. Could you please fax the EOB? If not then mail it or provide the source to get the EOB?
4. May I have the claim# & call ref#?
so are you available
ReplyDeleteClaim denied for Super bill. Can you help me with this denial.
ReplyDeleteYou can follow the below scenario, just replace medical records with the super bill.
Deletehttps://www.arlearningonline.com/2019/11/226-information-requested-from.html
Hi, thank you for this.
ReplyDeleteCan you also include what will we do if the claim has a denial of "CO261 The procedure or service is inconsistent with the patient's history."?
Again, thank you so much!
Please follow the below scenario,
Deletehttps://www.arlearningonline.com/2019/12/181-procedure-code-was-invalid-on-date.html
Thank you!
Nice website
ReplyDeleteThanks!
DeletePlease add a scenario where the initial payment has been recouped and no detailed explanation in the EOB received. What questions are we going to ask to the payer? Thank you.
ReplyDeleteIf no details are available in the EOB then we can only make a call to insurance and ask for a recoupment reason and based on the reason provided by the rep, a specific scenario can be followed.
DeleteHello, if we get the denial as The disposition of the claim/service is undetermined during the premium payment grace period, per Health Insurance Exchange requirements. This claim/service will be reversed and corrected when the grace period ends (due to premium payment or lack of premium payment, what will be the next action
ReplyDeleteIt seems that the patient failed to pay the premium and insurance is waiting for the payment as the grace period has not ended yet. You may bill the claim to the patient or may set the follow-up till the grace period is over. Please get confirmation from your client for the final action.
Deleteneed
ReplyDeleteBCBS numbers
Please follow the below post for the insurance phone number,
Deletehttps://www.arlearningonline.com/2020/01/insurance-phone_26.html
AR NEED REVERSAL PAYMENT INSURANCE SAID
ReplyDeleteIt means that the insurance has overpaid or paid the claim in error.
DeleteIn such a scenario, there are 2 possibilities,
1. Insurance may adjust this amount in future payments.
2. Insurance can ask for a refund of the paid amount.
If it is being asked to refund the payment then you can ask for the steps to refund the payment from the insurance rep. As an AR, normally these steps do not need to be followed. There is a separate team that works on this scenario. You may confirm with your supervisor and route the claim to that department.
can any one tell me the resolution of "Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services)"
ReplyDeletePlease follow the below scenario,
Deletehttps://www.arlearningonline.com/2019/12/234-this-procedure-is-not-paid.html
If the patient has 2 insurances, and both still have balance in the system, what should be done first? TIA
ReplyDeleteWork on primary insurance balance first. Try to find the reason for the primary insurance balance and resolve it first. Once it is resolved then you can work on the secondary insurance balance.
DeletePlease note if primary insurance repays the claim then it must be resubmitted to secondary insurance with an updated EOB. Secondary insurance would also make the payment adjustment as per the updated EOB.
When we are submitting claim second time for secondary insurance with updated eob do we need to submit corrected claim?
Deletecan anyone help how to work on SNF denial
ReplyDeleteTrustMark insurance denied the claim stating Provider Accepts Medicare Assignment, what to do in this scenario ?
ReplyDeleteIt seems that Medicare is the primary payer. Please check the eligibility and submit the claim to Medicare if active.
DeletePlease confirm if the above assumption is incorrect.
Thanks
DeleteI have one question about pt plan denial
ReplyDeletePlease share your question.
DeleteHow to solve Overpayment claim pls reply my Query related to Overpayment as claim initially got paid and it was got recouped on emergency claim,checked previous patients claims account summary nothing found.when called ins rep stated cliam was was recouped b'coz of we overpaid claim as informed to rep no overpaid claim found,rep doesn't provide the more information on this.From your perspective or insurance side what user can prob rep over on call and what to ask next and end action?
ReplyDeleteSometimes, insurance pays in an error more amout than the allowed amount on a claim and if the additional amount is not refunded by the provider then insurance makes the adjustment of additional payment to any other claim in the future and it is not necessary that the adjustment of additional payment will be from the same patient.
DeleteWhen getting any such scenario, it is good to ask for patient information where additional payment was made previously and if the rep is not providing this information on call then you can ask for EOB. On an EOB, you may get this information.
Cigna (Primary) denied CPT- 36415 as it got bundled with CPT- 82306, and we already billed 36415 in another claim on the same DOS so it exceeded the max allowed units in one day. So is it possible if we append modifier 59 with 36415 to get it paid as it also exceeded the max allowed units per day ?
ReplyDeleteCPT 82306 cannot be bundled with CPT 36415. This denial does not look correct. But, if it already exceeds the max allowed then it will not get paid.
DeleteOkay thanks.
DeleteCigna denied CPT- 86769 as the diagnosis code is not covered under this CPT and as per our coder's review, there is no other DX code payable. DX billed are- Z20.822, J02.9, J06.9, R60.0. We cannot write the CPT as is it of $739 charged amount, so is there any other option left?
ReplyDeleteIf the patient was not inpatient then the Dx Z20.822 can be moved to any other place from the primary position.
DeleteThanks
Deleteit's very helpful to freshers.
ReplyDelete👍
DeleteCan anybody help me from where to get the Fee Schedule of all the insurance companies, whether I should call the insurance one by one to get then or I can get then at one place? like CMS or any other option?
ReplyDeleteMany insurance make the payment as per the Medicare fee schedule. In that case, you can download the fee schedule from the CMS website. But, if the insurance does not follow Medicare then you need to make a call and ask for a fee schedule.
Deletehttps://www.arlearningonline.com/2021/03/how-to-pull-physician-fee-schedule-from.html#
Help on the denial reason co-109 which has denied as service not covered by this payer in this scenario if claim denied by Medicare and stating the denial reason 109 and we found out that patient has an Medicare advantage plan and we send the claim to hmo and after that claim process and paid under hmo and left the co insurance so in that scenario we need to bill to co ins to Medicare as a secondary insurance?
ReplyDeleteNo, the claim cannot be billed to Medicare as secondary. When there is a Medicare Advantage Plan available then it pays on behalf of Medicare as primary. After its processing, the claim should be billed to other available secondary insurance. It should never be billed to Medicare.
DeleteThank you so much
DeleteThe claim is denied by Cigna as the patient's plan does not cover telemedicine service the POS is 2 and the plan type is PPO, what can we do in this case ?
ReplyDeleteIf the patient plan does not cover telemedicine service then all the telemedicine services taken by the patient will be the patient's responsibility.
DeleteWhat is the denial 234 and how to solve this denial?
ReplyDeleteYou can follow the below post,
Deletehttps://www.arlearningonline.com/2019/12/234-this-procedure-is-not-paid.html
Cigna denied CPT 76700 stating this service is not payable to this provider based upon the provider's contract. The DX codes billed are R79.89 & K80.20, what can we do in this ? ref# 3678618.
ReplyDeleteIt seems that the denial is nowhere related to DX. So, no need to make any changes in DX. Please follow the below scenario to work on this denial,
Deletehttps://www.arlearningonline.com/2019/11/96-non-covered-charges.html
Thanks
DeleteMolina health insurance denied cpt 93976 - Mutually exclusive procedures cannot be done in the same day/setting.Exclusive with cpt 76856 modifier also appended. so what can we do?
ReplyDeleteAppeal
DeleteWhich modifier is appended?
DeleteDenial code 246 is a non-payable code used for reporting purposes only
ReplyDeleteWe are Hospice Provider facing issue in billing Physician Services to Medicare. Rev code 0657 but unable to fine any relevant HCPC. We have been trying G0299 and G0300 with GV modifier. But claim backs to RTP always.
ReplyDeleteAny help ???
Is there any denial or rejection reason provided by Medicare?
DeleteOVERPAYMENT ON CALL SCENARIOS KINDLY UPDATE
ReplyDeleteJust want to confirm the scenario that you are looking for, can you please confirm the below points?
Delete1. Is the CPT overpaid? and you are making a call to correct it.
2. Is it paid and applied towards offset and the overpayment made on some other claim?
Team, If Medicare partially paid suppose one cpt paid and second cpt denied and crossed over to secondary secondary also paid only for the paid cpt later corrected the denial medicare paid for denied cpt and left co insurance didn't crossover to secondary how to handle this scenario
ReplyDelete