Duplicate Denial Scenario

Meaning:  The claim submitted has already been processed by the insurance. A similar service was performed for the same patient on the same date by the same provider or multiple providers.

Claim Adjustment and Remark  Codes:

CO18	Duplicate claim/service
N20	Service not payable with other service rendered on the same date
N347	Your claim for a referred or purchased service cannot be paid because payment has already been made for this same service to another provider by a payment contractor representing the payer
M86	Service denied because payment already made for same/similar procedure within set time frame
CO-B20	Procedure/service was partially or fully furnished by another provider

Reasons:

1. The procedures on the claim could have been done more than once on the same DOS due to medical necessity either by the same physician or two different physicians.
2. The claim could have been refiled as the original claim never reached the insurance and the original claim was received eventually.
3. The service was performed by another provider, outside your practice or group, on the same day as your service, and payment has already been made to that provider. 
4. The same claim was generated twice as the same charge sheet was processed by two different Charge Entry operators. 
5. A corrected claim was sent.

Steps to resolve :

1. Check whether the billing software shows more than one claim for the same DOS.
2. If there is only one claim, check the claim filing history to know how many times the same claim was refiled.
3. If there was a refiling made need to get the status of the original submission.
4. If there were two claims, need to check if there are appropriate modifiers to differentiate the claims. If yes, need to call the insurance and request them to reprocess the claim.
5. If there were no proper modifiers, then we need to move the claim for coding review to check whether there was a medical necessity and get relevant modifiers coded.
6. If the denial was a corrected claim, need to call the insurance and mention the differences, and request them to reprocess.
7. If the claim was generated due to charge entry errors, suggest write-off the denied claim.  

The service was performed by another provider, outside of your practice or group- This can only be resolved by contacting the insurance company. Ask the insurance company for their policy on appealing such a denial, each insurance has its own process for doing this.

Note:

This scenario can be worked upon without calling. Calling is needed only when we need the claim to be reprocessed by the insurance.

Calling Flow Chart:

Mock Call Questions:

• When did the claim get denied? 
• May I know to which claim it is being denied as a duplicate? 
• What is the status of the original claim? 
• What are the rendering provider names on the initial claim and the denied claim? 
• What are the procedure codes and Diagnostic codes on the initial claim and the denied claim? 
• Do you show or have a modifier on the claim to indicate the same service provided on the same day by the physician? 
• What is the appeals’ address? 
• What is the appeals filing limit? 
• Can you please fax me a copy of the EOB? 
• May I have the claim number, please? 
• May I have the call reference number, please?

Notes format for Duplicate denial:

Case	Description	Documentation
1	Only one claim with the same DOS, billed amount found in billing software.	Called Aetna @ 1-800-679-4579. Spoke to rep Cynthia. Rep said that the claim with DOS 12/05/2019,charge $200.00 was denied as a duplicate. Clm was denied on 01/31/2020. Claim received on 01/30/2020. Reviewed the billing software and found that there is only one claim with the same DOS and billed amount. As per the claim history, the claim has been filed more than once. Verified the details of the claim with the rep and the one in the system – Patient’s name, policy id, procedure code, modifiers, billed amount, diagnosis code, rendering physician NPI, referring physician NPI, Tax Id, Billing provider name. Found that the claim with the rep was an exact duplicate. Rep informed that the original claim was denied for untimely filing….. Requested for a copy of the EOB to be faxed @ 1-800- 123-1234 (Attention: Dr.Daniel Brown). Claim# 123456789. Call ref# A123456.
2	More than one claim with the same DOS, billed amount found in billing software.	Called Aetna @ 1-800-679-4579. Spoke to rep Cynthia. Rep said that the claim with DOS 12/05/2019,charge $200.00 was denied as a duplicate. Clm was denied on 01/31/2020. Claim received on 01/30/2020. Reviewed the billing software and found that there are 2 claims with the same DOS and billed amount. Verified the details on both the claims – Patient’s name, policy id, procedure code, modifiers, billed amount, diagnosis code, rendering physician NPI, referring physician NPI, Tax Id, Billing provider name. Found them to be exactly the same.Requested for a copy of the EOB to be faxed @ 1-800- 123-1234 (Attention: Dr.Daniel Brown). Raised coding review task for reviewing the medical records and assigning suitable modifiers. Claim# 123456789. Call ref# A123456.
3	Incorrectly denied	Called Aetna @ 1-800-679-4579. Spoke to rep Cynthia. Rep said that the claim with DOS 12/05/2019,charge $200.00 was denied as a duplicate. Clm was denied on 01/31/2020. Claim received on 01/30/2020. Reviewed the billing software and found that there are 2 claims with the same DOS and billed amount. Verified the details on both the claims – Patient’s name, policy id, procedure code, modifiers, billed amount, diagnosis code, rendering physician NPI, referring physician NPI, Tax Id, Billing provider name. Found a difference in the modifier. Hence sent the claim for reprocessing. The reprocessing time is 15 business days. Need to follow up after 20 business days. Claim# 123456789. Call ref# A123456.

MOCK CALL CONVERSATION VIDEO (US REP AND AR CALLER) FOR DUPLICATE DENIAL: