ARCALLING 49 DENIAL SCENARIOS

1. Patient not on file  or Patient cannot be identified as our insured

(Adjustment reason code:  31)

1. Check with the patient’s name, date of birth, first name, last name, and SSN number.
2. If the rep found the patient then get the correct policy number and corrected claim mailing address and time frame in order to resubmit
3. If the rep is unable to pull with these, then the patient may not have a policy
4. That patient would have different insurance
5. Call reference number?

End action:

• Assign to client assistance to find active/correct insurance details
• If no active insurance then bill the patient

2. Claim not on file:

1. Could you please check Whether the Patient is eligible for the date of service?
2. May I have the claim’s mailing address? 
3. May I have the Timely filing limit to resubmit?
4. Call reference number?

End action

• If the patient is eligible then get the correct mailing address and payor id and resubmit
• If the patient is not eligible then BILL the patient to find active insurance

3. Claim in Process:

1. May I have the claim received date?
2. May I have a normal claim processing time?
3. If it is within 30 days ‘from the day you are calling then close the call with a Claim number and Call reference number
4. If it is more than 30 days get the delay reason of claim processing
5. Claim number?  and
6. Call reference number?

End action:

• If the claim received recently (below 30days) please be allow some more time
• If the claim is received (over 30days) ask the rep to escalate to process soon

4. Denied Additional Information from the Patient or COB update needed

(Adjustment reason code:  CO 22)

1.  May I know the claim denied or pending date?

2.  May I know What information is required?

(If rep says COB update needed from the patient)

3.  Ask the rep may I know did you send a letter to the patient?

4.  If the rep says yes then ask may I know how many letters were sent so far and When was the last letter sent?

5. Have you received any response from the patient?    

6. If no response from the patient then Ask the rep Can you please send one more letter If possible? 

7. May I know When did patient last updated the COB information?

8. May I know the member service number in order for the patient to update the COB?

9. Claim number?

10. Call reference number?

End action:

• If the letter was sent to the patient has not crossed 30 days allow some more time.
• If the letter was sent has crossed 30 days then bill the claim to the patient.
• If the claim is denied for COB update then check the patient payment history if the payment on nearby DOS is received from any other insurance as a primary then check the eligibility of that insurance and bill the claim to that insurance.

5. Claim processed towards deductible:

(Adjustment reason code:  1)

Claim processed towards deductible Less than 30 days

1. May I have the claim Processed Date?
2. What is the Deductible amount allowed for this claim?
3. May I have the Annual Deductible amount?
4. May I know it is a Family or individual Deductible?
5. May I know it is In-network or out-of-network Deductible?
6. How much met by the patient as of this claim
7. Claim number?
8. Call reference number?

Claim processed towards deductible More than 30 days

1. May I have the claim Processed Date?
2. What is the Deductible amount allowed for this claim?
3. May I have the Annual Deductible amount?
4. May I know it is Family or individual Deductible?
5. May I know it is In-network or out-of-network Deductible?
6. How much is met by the patient as of this claim?
7. Request for a copy of EOB to the pay to address or fax  number
8. Claim number?
9. Call reference number?

End action:

• Once the EOB is received then, check patient has a secondary payer if the secondary payer is available check the eligibility of the secondary payer and submit with this EOB
• If no secondary payer then bill the patient with a patient statement

6. Claim Paid  within 30 days:

1. May I know the claim paid date?
2. May I know the Allowed Amount?
3. May I know the Paid Amount?
4. May I know the Patient’s Responsibility?
5. May I know it was Paid through a Check or EFT number?
6. May I know it is a Single or Bulk check?
7. May I know To which address the ‘EOB or remittance was initiated?
8. Claim number?
9. Call reference number?

End Action: 

• Allow some time to receive the EOB once the EOB received the send to the posting team

7. Claim Paid more than 30 days:

1. May I know the claim paid date?
2. May I know the Allowed Amount?
3. May I know the Paid Amount?
4. May I know the Patient’s Responsibility?
5. May I know it was Paid through a Check or EFT number?
6. May I know it is a Single or Bulk check?
7. May I know the Cash date?
8. (If No cash date) ask rep Could you please do a check trace?
9. May I know To which address the ‘EOB or remittance was initiated?
10. Since it is over 30 days then Again Request a copy of paid EOB to the Pay to Address or Fax number
11. Claim number?
12. Call reference number?

End Action: 

• Once the check trace is initiated wait till the time given by the rep and then call back to find out where the check was sent to.
• If the check sent to a different address ask to reissue a new check

8. Claim Denied for Medical Records:

(Adjustment reason code:  226)

1. May I have a claim pending or denied Date?

2. May I know What medical record is required?

( If the rep doesn’t have a specification of the record, mention the same in the claim )

 (Check in the system whether any medical records are available or already sent to the payer)

3. (If medical records were not sent get the mailing address) May I have the mailing address to submit the medical records?

4. May I know the Timely filing limit to submit the medical records?

5. Claim number?

6. Call reference number?

End action:

• If medical records are found in the system then submit it to the payer
• If no medical records are found then escalate to the client to attach the medical records once medical records are attached then submit them to the payer

9. Claim denied for Pre-existing information or additional information needed:

(Adjustment reason code:  51)

1.  May I know the claim denied or pending date?

2.  May I know What information is required?

 (If rep says pre-existing Information is needed from the patient)

3. May I know the start and end date of the waiting period

4. Ask the rep may I know did you send a letter to the patient?

5. If the rep says yes then ask may I know how many letters were sent so far and When was the last letter sent?

6. Ask the rep Can you please send one more letter (If possible )?

7. May I know the mailing address to send and what is the timely filing limit?

9. Claim number?

10. Call reference number?

End action:

• If DOS lies within the waiting period then bill the claim to the patient.
• If DOS does not lie between the waiting period then ask the rep to reprocess
• Do not bill the claim to a secondary or consecutive payer since they are not going to process the claim.

10. Claim  denied for Invalid CPT : 

(Adjustment reason code: 181)

1. May I know the claim denied date?

(Check in the claims history and see whether the denied CPT is paid before any date of service by the same payer) If it is paid cross verify with the rep

2.  Upon checking the patient’s claims summary found this same CPT code was paid previously on another Date of service and the Date of service is …… could you please verify this?

If the rep checked and found then ask him to reprocess

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call reference number?

End action:

• Check payment history, If the same CPT was already paid on another DOS then verify with the rep and reprocess
• If no payment is found previously on this CPT code then send it to the coding team to find the correct CPT once the coding team updates with the new CPT code then resubmit as a corrected claim.
• If the coding team states that the procedure code is coded correctly then send an appeal to insurance.

11. Claim Denied for Invalid Or Missing Modifier: 

(Adjustment reason code: 182)

1. May I know the claim denied date?

(Check in the claims history and see whether the denied CPT  and modifier is paid before any date of service by the same payer) If it is paid cross verify with the rep

2. Upon checking the patient’s claims summary found this same CPT code and same modifier were paid previously on another Date of service and the Date of service is …… could you please verify this?

If rep checked and found then ask him to reprocess

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• Send to the coding team to review and provide correct modifier and once response is received with correct modifier  then send corrected claim to insurance by updating correct modifier
• If the coding team states that the modifier is correct then send an appeal to insurance.

12. Claim Denied for Invalid Or Missing Diagnosis:

(Adjustment reason code: 146)

1. May I know the claim denied date?

2. Could you please tell me which diagnosis code  is invalid (If there are multiple DX codes coded)

(Check in the claims history and see whether the denied CPT code and diagnosis code combination was paid before any date of service by the same payer) If it was paid cross verify with the rep

2. Upon checking the patient’s claims summary found this same CPT code and diagnosis code combination was paid previously on another Date of service and the Date of service is …… could you please verify this?

(If rep checked and found then ask him to reprocess)

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid , get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• Send to the coding team to review and provide correct dx code and once response received with correct dx details then send corrected claim to insurance by updating correct dx code.
• If the coding team states that the dx code is correct then send an appeal to insurance.

13. Claim Denied for Invalid Place of service:

(Adjustment reason code: 58)

1. May I know the claim denied Date?

2. Could you provide the correct place of service?

(If rep provides get the corrected claim address and time frame for corrected claim)

3. May I know the corrected claim mailing address and the timely filing limit?

(If the rep refused to provide the place of service then verify any hospital claim received on this date of service?)

4. Could you please check is there any hospital claim received on this date of service? this is because we can use the Place of service billed in the hospital claim for our physician’s claim

(If no hospital claim was received then ask for the corrected claim information)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• If the rep provides a correct place of service then update it and send a corrected claim
• If the rep does not provide then assign the claim to the coding team to review and provide a correct place of service
• When the response is received as coding is correct again call insurance and try to reprocess the claim if the rep disagrees then ask for appeal details and send an appeal to insurance.

14. Claim denied for CPT Inconsistent with a modifier or Billed CPT is not valid for the modifier or vice versa : (Adjustment reason code: 4)

1. May I know the claim denied date?

(Check in the claims history and see whether the denied CPT  and modifier combination  was paid before any date of service by the same payer) If it was paid cross verify with the rep

2. Upon checking the patient’s claims summary found this CPT  and modifier combination was paid previously on another Date of service and the Date of service is …… could you please verify this?

(If rep checked and found then ask him to reprocess)

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• Send to the coding team to review for correct modifier and once response received with correct modifier  then send corrected claim to insurance by updating correct modifier
• If the coding team states the modifier and CPT code combination is correct then send an appeal to insurance.

15. Claim denied for  CPT Inconsistent with Diagnosis or Billed CPT is not valid for the Diagnosis or vice versa :(Adjustment reason code: 11)

1. May I know the claim denied date?

2. Could you please tell me which diagnosis code  is invalid (If there are multiple DX codes coded)

(Check in the claims history and see whether the denied CPT code and diagnosis code combination was paid before in any date of service by the same payer) If it was paid cross verify with the rep

2. Upon checking the patient’s claims summary found this same CPT code and diagnosis code combination was paid previously on another Date of service and the Date of service is …… could you please verify this?

(If rep checked and found then ask him to reprocess)

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• Send to the coding team to review for correct Diagnosis code and once response received with correct modifier  then send corrected claim to insurance by updating correct Diagnosis code
• If the coding team states the Diagnosis code and CPT code combination are correct then send an appeal to insurance.

16. Claim Denied for CPT Inconsistent with Place of service or Billed CPT is not valid for the billed Place of service or vice versa: (Adjustment reason code: 5)

1. May I know the claim denied Date?

2. Could you provide the correct place of service?

(If rep provides get the corrected claim address and time frame for corrected claim)

3. May I know the corrected claim mailing address and the timely filing limit?

(If the rep refused to provide the place of service then verify any hospital claim received on this date of service?)

4. Could you please check is there any hospital claim received on this date of service? this is because we can use the Place of service billed in the hospital claim for our physician’s claim

(If no hospital claim was received then ask for the corrected claim information)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• If the rep provides a correct place of service then update it and send a corrected claim
• If the rep does not provide then assign the claim to the coding team to review and provide the correct place of service
• When the response received as coding is correct, again call insurance and try to reprocess the claim if the rep disagrees then ask for appeal details and send an appeal to insurance.

17. Claim Denied for CPT Inconsistent with Patients Age:

(Adjustment reason code: 6)

There are few CPTs defined based on the age of the patient. When it is billed incorrectly then this denial occurs.

1. May I know the claim denied date?

(Check in the claims history and see whether the denied CPT is paid before any date of service by the same payer) If it is paid cross verify with the rep

2.  Upon checking the patient’s claims summary found this same CPT code was paid previously on another Date of service and the Date of service is …… could you please verify this?

If the rep checked and found then ask him to reprocess

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action: 

• Send to the coding team to review and provide the correct CPT. Once a response is received with correct CPT  details then send the corrected claim to insurance by updating the correct CPT.
• When the response received as coding is correct then call insurance and try to reprocess, if the rep disagrees then ask for appeal details and send an appeal to insurance.

18. Claim Denied for CPT Inconsistent with Patient Gender:

(Adjustment reason code: 7)

There are few gender-specific CPT. For example, 81025 denotes a Urine pregnancy test. When it is billed to the male patients then this denial occurs.

1. May I know the claim denied date?

(Check in the claims history and see whether the denied CPT is paid before any date of service by the same payer) If it is paid cross verify with the rep

2.  Upon checking the patient’s claims summary found this same CPT code was paid previously on another Date of service and the Date of service is …… could you please verify this?

If the rep checked and found then ask him to reprocess

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber? 

End action: 

• When getting this denial, always check patient eligibility since gender could be updated incorrectly while updating patient information then update correct gender information and resubmit the claim.
• Send to the coding team to review and provide the correct CPT. Once a response is received with correct CPT  details then send the corrected claim to insurance by updating the correct CPT.
• When the response received as coding is correct then call insurance and try to reprocess, if the rep disagrees then ask for appeal details and send an appeal to insurance.

19. Claim Denied for Non covered service as per Payer’s Guidelines:

(Adjustment reason code: 96)

1. May I know the claim denied date?

 (When the rep, states the claim denied for noncovered service check under what criteria it is noncovered)

2. May I know if it was non-covered as per provider contract or patient plan or payer guidelines?

 (If it is payer guidelines, check-in the claims history whether the same CPT and DX code combination was paid previously)

 3.  Upon checking the patient’s claims summary found this same CPT code was paid previously on another Date of service and the Date of service is …… could you please verify this?

If the rep checked and found then ask him to reprocess

3. So could you please send this denied claim for reprocessing and what is the time frame for reprocessing?

(If previously  not paid, get the corrected claim mailing address with the timely filing limit)

4.  May I know the corrected claim mailing address and the timely filing limit?

5. Claim number?

6. Call referencenumber?

End action:

• Check to bill/claims history to whether this same CPT code was paid already if found give that DOS to the rep and get clarification on how it was paid and ask to send the current claim for reprocessing.
• If no previous dos were paid on this code then send it to the coding team to verify the coding
• If the coding team says the coding is already correct then send an appeal.

20. Claim Denied for Non covered service as per Patients Benefit Plan:

(Adjustment reason code: 96)

1. May I know the claim denied date?

(When the rep, states the claim denied for non-covered service check under what criteria it is non-covered)

2. May I know it was non-covered as per provider contract or patient plan or payer guidelines?

3. If it is a patient benefit plan,  check-in the claims history whether the same CPT was paid previously if yes ask to reprocess by giving that previous date of service, if no previous payment is found then follow the next question

4. ask rep ‘What is the reason for non-covered’?   

 (If the rep says DX is incorrect then get the corrected claim mailing address with the timely filing limit)

5.  May I know the corrected claim mailing address and the timely filing limit?

If the rep says the provider is out of network under a patient plan the following provider is out of network scenario

6. Claim number?

7. Call referencenumber?

End action: Bill the patient.

• Check billing/claims history to whether this same CPT code was paid already if found give that DOS to the rep and get clarification on how it was paid and ask to send the current claim for reprocessing.
• If no previous dos were paid on this code then send it to the coding team to verify the coding
• If the coding team says the coding is already correct then send an appeal.
• If the appeal is denied then request the EOB through fax or mail
• This can be billed to a secondary or consecutive payer. 
• If no other payer is found then bill the patient.

21. Claim Denied for Non covered service as per Provider Contract:

(Adjustment reason code: 96)

1. May I know the claim denied date?

(When the rep, states the claim denied for non-covered service check under what criteria it is non-covered)

2. May I know if it was non-covered as per provider contract or patient plan or payer guidelines?

3. If it is a Provider Contract,  ask the rep ‘What is the reason for non-covered’?   

(If rep says CPT non covered under  Provider Contract then check in the claims history whether the same CPT paid previously if yes ask to reprocess by giving that previous date of service if no previous payment found then follow next question

4.  May I know the appeal mailing address and the timely filing limit?

5. Claim number?

6. Call the reference number?

End action: Write-off or adjustment

• Check billing/claims history whether this same CPT code was paid already if found give that DOS to the rep and get clarification on how it was paid and ask to send the current claim for reprocessing.
• If no previous dos were paid on this code then send to the coding team to verify the coding
• If the coding team says the coding is already correct then send an appeal.
• If the appeal is denied then request the EOB through fax or mail
• Once you received the EOB then send it to posting and adjust the claim

22. Claim Denied for Maximum Benefit Exhausted

(Adjustment reason code: 119)

1. May I know the claim denied date?

2. May I know the maximum benefit reached in terms of dollar or visit?

(If it is In terms of Dollars per year? or per month? )    

3. How much Dollar amount is allowed per year?

4. How much dollar amount has the patient met?   ( If the patient has met the maximum allowed dollar amount previously)

5. May I know on which date of service the patient has met the maximum dollar amount?

6. Could you please fax or mail the EOB?

7.  May I know the  Claim number and Call reference number?

( If the patient has NOT met the maximum allowed dollar amount and still has a balance in it)

8.  So could you please send this claim for reprocessing? 9. What is the reprocessing time?

10. May I know the  Claim number and Call reference number?

(same question In terms of Visits per year? or per month?)    

3. How many visits are allowed per year?

4. How many visits has the patient met and when was the last visit made?     

( If the patient has met the maximum visits previously) 5. Could you please fax or mail the EOB?

6.  May I know the  Claim number and Call reference number?

( If the patient has NOT reached the maximum allowed visits  previously)

7.  So could you please send this claim for reprocessing? 8. What is the reprocessing time?

9. May I know the  Claim number and Call reference number?

End action: 

• If a patient has met the allowed dollar amount or visits excluding this claim then the claim must be billed to the secondary payer/consecutive payer or patient.
• If no other payer is active or available on DOS then bill the claim to the patient.

23. Claim Denied for Bundled. Experimental. Not separately reimbursable

(Adjustment reason code: 97)

1. May I know the claim denied date?

2. May I know  To which CPT it is bundled with?

(Check whether a corrected claim or appeal is possible) if both is possible get both details 

3. What is the corrected claim address and time limit to send the corrected claim?

4. What is the appeal address and time limit to send an appeal?

5. May I know the  Claim number and Call reference number?

End action: 

• Send to the coding team to Check the NCCI edit between procedures
• If the coding team responded with the correct modifier then send a corrected claim to insurance.
• If the coding team responded as the coding is correct then call the insurance and ask them to reprocess the claim. if they deny then send an appeal to insurance.

24. Claim Denied for CPT included with surgery procedure code or Globally Inclusive

(Adjustment reason code: 97)

1. May I know the claim denied date?

2. May I know  To which CPT it is included?

3. When was the main surgery performed?

4. May I What is the Global period?  (Global period is from 10 to 90 days) 

Calculate the time starting from the main surgery date to the current date of service.  

If the Date of service lies between the global period then

(Check whether a corrected claim or appeal is possible) if both is possible get both details 

5. What is the corrected claim address and time limit to send the corrected claim?

6. What is the appeal address and time limit to send an appeal?

7. May I know the  Claim number and Call reference number?

If the Date of service does not lie between the global period then

8. Could you please send this claim back for reprocessing?

9. What is the reprocessing time?

10. May I know the  Claim number and Call reference number?

End action: 

• When the DOS is between the Global period range then it should be written off but there is a possibility to separate out the procedure with main surgery by adding modifier as well, so assign it to the coding team for clarification.

25. Claim Denied for Patient is Not Eligible for the Date Of Service OR Expenses incurred after coverage terminated: (Adjustment reason code: 27)

 1. May I know the claim denied date?

2. May I have the policy effective and termed date?

(If DOS lies between effective and termed date)

3. Could you please send this claim back for reprocessing?

4. What is the reprocessing time?

5. May I know the  Claim number and Call reference number?

(If the date of service does not lie between effective and termed date!)

6. Is there any other policy active for this patient on this date of service? 

(If the rep says yes get that policy details) 

7. May I have a policy ID?

8. May I have the Policy effective and termed date?

9. May I know the  Claim number and Call reference number?

(If no other active policy is found )

10. May I know the  Claim number and Call reference number?

End action:  Bill patient

• Bill patient if no other active insurance is available.
•  When other insurance is available then make it primary and resubmit the claim. 
• Always check previous DOS, if payment from any other insurance was received or not. If yes, then check the eligibility for that payer for DOS and resubmit the claim to that insurance. 

26. Claim denied for Patient is in HOSPICE

(Adjustment reason code: B9)

1. May I know the claim denied date?

2. May I have the start date and end date of the hospice enrollment

(Check if the date of service lies between the hospice start date and end date) 

If yes

3. So could you please send this claim for reprocessing and What is the reprocessing time?

4. May I know the  Claim number and Call reference number?

If no

5. May I have the hospice name, NPI, mailing address, and policy ID?

6. May I know the  Claim number and Call reference number?

End action:  

• Attending physician” who is not an employee of the designated hospice then should be submitted to Medicare part B with GV modifier.
• Any services provided to a patient that is not related to hospice condition should be submitted to Medicare Part B with GW modifier.
• Sometimes, insurance does not provide hospice information and gives an NPI number. In such a scenario, use the NPPES website to obtain the hospice name and mailing address. Also, SSN can be used as a policy ID. This NPI number can also be found on the Medicare portal under the hospice tab.

27. Claim Denied for patient ID is Invalid 

(Adjustment reason code: 140)

1. When verifying the patient’s information, the rep states patient is not found

2. Check with the patient’s name and date of birth

3. Patient will be pulled and the Member ID will be different from the payer’s system

4. Get the correct member id and mention it in the claim notes

5. Get the corrected claim mailing address and time limit

6. Claim#?

7. Call reference#?

End action:  

• Get the correct member id from the rep and submit the corrected claim with the correct member id
• If the rep doesn’t provide it to you then assign it to client assistance

28. Claim Denied for Invalid Patient Name:

(Adjustment reason code: 140)

1. When verifying the patient’s information, the rep states unable to pull the patient
2. The reason is Name of the patient is mismatched with the payer’s system
3. Get the correct Patients name and mention it in the claim notes
4. Get the corrected claim mailing address and time limit
5. Claim#?
6. Call reference #?

End action:  

• Get the correct member id from the rep and submit the corrected claim with the correct member id
• If the rep doesn’t provide to you then assign to client assistance.

29. Claim denied for Provider ID missing:

1. Legacy #, PTAN, Provider ID all terms are the same
2. When the rep is asking what is the provider ID, check the provider’s Information TAB
3. If the information is not available, then the denial is correct
4. Get what is the procedure to obtain the provider ID from the payer
5. Update and get the corrected claim mailing address with a time limit
6. Claim?
7. Call reference#?

End action:  

• Check the NPPES website (https://npiregistry.cms.hhs.gov/) to find the PTAN, if PTAN is available then update and submit a corrected claim
• No PTAN is available then the denial is correct so adjust(write-off) the claim 

30. Claim denied for Provider ID Invalid:

1. Legacy #, PTAN, Provider ID all terms are the same
2. When the rep is asking what is the provider ID, check the provider’s Information TAB
3. If the information is available, cross verify with that number
4. If the number is correct ask the rep to send it back for reprocess
5. If the information is not available, then the denial is correct
6. Get what is the procedure to obtain the provider ID from the payer
7. Update and get the corrected claim mailing address with the time limit
8. Claim#?
9. Call reference#?
   

End action:  

• Check the NPPES website (https://npiregistry.cms.hhs.gov/) to find the PTAN, if PTAN is available then update and submit a corrected claim
• If no PTAN is available then the denial is correct so adjust(write-off) the claim 

31. Claim denied for Invalid Patient’s DOB:

1. When verifying the patient’s information, the rep states unable to pull the patient
2. The reason is DOB of the patient is mismatched with the payer’s system
3. Get the correct Patient’s DOB and mention it in the claim notes
4. Get the corrected claim mailing address and time limit
5. Claim#
6. Call reference#

End action:  

• Get the correct DOB from the rep and submit a corrected claim with the correct name.
• If the rep doesn’t provide to you then assign to client assistance.

32. Primary Paid Maximum OR  Primary paid more than the secondary allowed amount

(Adjustment reason code: 23)

1. When the secondary payer states primary paid maximum
2. Get the secondary’s allowed amount
3. Compare it with the primary paid amount
4. If it is more than the secondary’s allowed amount then the denial is correct
5. If it is less than the secondary’s allowed amount then ask the rep to reprocess
6. Claim #?
7. Call reference #?

End action:  

• If the primary paid amount is more than or equals to the secondary allowed amount then write off the charge.
• If the primary paid amount is less than the secondary allowed amount then it’s secondary insurance’s responsibility to pay the remaining amount. Ask the rep to reprocess.

33. Claim Denied for Missing or Invalid NDC number:

(Adjustment reason code: M119)

NDC # is updated for Drug codes

1. When the rep states this code is denied for NDC #, check in the line item and
2. claim form whether NDC # is available or not
3. If NDC #Is not available then get the corrected claim mailing address with
4. time limit to resubmit
5. If NDC # is available then verify with the rep whether the # is valid or not
6. If it is valid then the claim will be taken back for reprocessing
7. If not valid get the corrected claim mailing address along with the time limit
8. Claim#?
9. Call reference #?

End action:  

• NDC code requires only for Drug CPT code. The drug code always starts with a letter
  “J”. Example – J0256, J2425, J7649.
• In CMS1500 form, NDC code is available in the shaded portion of the line item field 24A
• If the rep has provided the correct NDC code then update it and submit a corrected claim
• If you do not have access to update the NDC number then assign to client assistance.

34. Claim Denied for CLIA #?

(Adjustment reason code: M120)

CLIA # is under for LAB CODES “8” Series codes example (80400-80439)

1. When a claim or code is denied for CLIA #check whether any number is updated in BOX 23 in the CMS-1500 Claim Form.
2. If the # is there verify with the rep on the same
3. If it is valid then the claim will be taken back for reprocessing
4. If it is not valid then get the corrected claim mailing address with a timely filing limit
5. Ask what is the procedure to obtain CLIA #
6. Claim#?
7. Call reference#?

End action:  

• CLIA Waived test needs to be billed with QW modifier along with CLIA number
• .If the rep has provided the correct CLIA number then update it and submit a corrected claim 
• If you do not have access to update the CLIA number then assign it to client assistance.
• CLIA certification number is billed on box 23 of the CMS-1500 Claim Form.

35. Claim denied for the provider is not enrolled (OR) Provider is not linked with group (OR) Provider is not affiliated: (Adjustment reason code: 185)

• When the rep states the provider is not linked with the group
• Check in the billing summary whether the individual provider got paid before or not
• Ask what is the procedure to Enrol in the group
• Get the resubmission method along with the mailing address with a timely filing limit
• Claim#?
• Call reference#?

End action:  

• Once the provider is enrolled then resubmit if not then adjust

36. Claim denied for The supervising or rendering provider’s NPI is not on file with the payer:

(Adjustment reason code: 185)

1. When the payer states individual provider NPI is not available or doesn’t match with what the payer has in their system
2. Ask is it possible to get the updated NPI available with the payer
3. If not get the corrected claim mailing address •
4. Timely filing limit?
5. Claim#?
6. Call reference#?

End action:  

• Resubmit as corrected claim with correct Rendering provider NPI.
• If correct Rendering provider NPI was not found then assign to client assistance

37. Claim denied for The billing provider or medical group’s ŅPI is either not on file with the payer:

(Adjustment reason code: 185)

1. When the payer states group provider NPI is not available or doesn’t match with what the payer has in their system
2. Ask is it possible to get the updated NPI available with the payer
3. If not get the corrected claim mailing address
4. Timely filing limit?
5. Claim #?
6. Call reference #?

End action:  

• Resubmit as corrected claim with correct GROUP NPI
• If correct GROUP NPI was not found then assign to client assistance

38. Claim Submitted to incorrect Address Claim Need to be Submitted to the Pricing network or a different address:

1. When the rep states the claim is not on file and when you verify with the address if the address is not matching with what we have submitted then the claim has been sent to the wrong address, Check with the rep if the Member ID should be the same
2. Get the correct address and update the notes
3. Timely filing limit?
4. Claim #?
5. Call reference #?

End action:  

• Resubmit to the correct mailing address provided by the rep

39. Claim denied for invalid group #:

1. If the group # is available cross verify, if it is correct then the claim will be taken back for reprocess
2. If the group # is invalid or missing then get the corrected claim mailing address 
3. Timely filing limit?
4. Claim #?
5. Call reference #?

End action:  

• Call the benefits & eligibility department of the payer and get the correct group#. Then Resubmit as corrected claim with correct GROUP#
• If correct GROUP# is not found then assign to client assistance.

40. Claim denied for provider non participating:

(Adjustment reason code: 38)

1. When the rep states the provider is not participating at the time of service,
2. Check before whether the same provider was participating or not
3. Ask the rep What plan does the patient has?  (HMO, PPO, EPO, POS)
4. If the patient’s plan is  PPO or POS ask to reprocess
5. Also, check-in the billing summary whether the same provider got paid after the date of service for which we are calling
6. Ask for appeal possibility and get the address with a timely filing limit
7. Claim #?
8. Call reference #?

End action:  

• HMO and EPO plan does not cover out of network benefit, so it can be billed to the secondary or consecutive payer
• If no other payer is active or available on DOS then bill the patient.

41. Claim Denied for Authorization:

 (Claim Adjustment Reason Codes: 197)

Simple questions for easy understanding 

1. Check what is the place of service. If the place of service is 23(emergency) then ask to reprocess.
2. If the place of service is inpatient then check with the payer rep whether the hospital claim is available to see if Auth # is updated in that claim
3. If it is available then the claim will be taken back for reprocessing
4. If it is not there also if the place of service is not inpatient then ask the rep is there any possibility to get retro authorization
5. If yes get the procedure on how to get retro authorization
6. If no, then get the appeal address with a time limit
7. Claim #?
8. Call reference #?

Same Auth denial but detailed questions for better understanding

 1. May I know the claim denied date?

(Check in the system if the Authorization number is Available or not) If yes! follow below questions

2. Upon checking my system I found an Authorization number could you verify and send this claim for (if the rep agrees!) 

3. What is the reprocessing time period?

(Rep checked authorization you have given and also it is valid for this DOS but the rep does not agree to send for reprocessing)

4. May I know what is the corrected claim mailing address and timely filing limit?.

(If no authorization number is found or the authorization number in the system is invalid!)

Always check the place of service in box number 24B If the place of service is 23 then ask the rep the below question

5. could you send this claim back for reprocessing because this is an emergency place of service?

6. What is the reprocessing time period?

If the place of service is not 23 then ask the rep the below question

7. Do you have the authorization number on file? if the rep says YES then ask the rep the below question

8. Could you reprocess with that authorization?

If the rep UNABLE to reprocess then get that authorization number from the rep and submit a corrected claim with that authorization number

9. So could you please provide me a corrected claim address and timely filing address.

If the rep says no authorization number was found on their side, then ask

10. Is there any hospital claim received on this DOS? if the rep says YES! then ask

11. Is there any authorization number billed on the hospital claim? if the rep says YES! then ask

12. Could you please use that authorization number and send the claim back for reprocessing? (if the rep does not agree to reprocess then get that authorization number from the rep and send it as a corrected claim)

(if no hospital claim is found or no authorization in hospital claim then ask) 

13. Is it possible to get Retro Authorization? if yes

14. What is the procedure to obtain Retro Authorization?

(If Retro Authorization is not possible get the appeal details)

15. May I know the appeal address and timely filing limit for appeal? 

16. Claim #? 

17. Call reference #?

End Action:

• 1. If Auth# is not available and Retro Auth# not possible then send an appeal with complete medical records to show the medical necessity
• 2.  If the payer still denies then write off the claim. 

42. Claim Denied for Referral:

(Adjustment reason code: 288)

1. A referral is missing or invalid
2. Check any # or referring provider information is available in the claim
3. If available cross-verify on the same
4. Ask the rep What plan does the patient has?  (HMO, PPO, EPO, POS)
5. If the patient plan is  PPO & EPO ask to reprocess
6. If HMO & POS plan then ask who is the PCP and their phone#
7. Get the corrected claim mailing address with the time limit
8. Claim #?
9. Call reference #?

End action:  

• Assign to client assistance to get the Referral from PCP
• PPO & EPO plan does not require a patient to visit a referring physician, so referral is not required whereas in HMO & POS plan, it is necessary to visit a referring doctor, so referral# is required.

43. Claim Denied for Not Medically Necessary:

(Adjustment reason code: 50)

1. Claim or code denied for not medically necessary
2. Check in the billing summary whether the same set of CPT and Dx codes got paid before
3. If yes cross-verify on the same
4. If not, then check any medical records submitted initially.
5. Verify with rep whether sent medical records were reviewed
6. If no medical records were sent, get the appeal address to update with proof that the denied code is medically necessary
7. Timely filing limit?
8. Claim #?
9. Call reference #?

End action:  

• Send to the coding team to review and provide the correct dx code and once a response is received with correct dx details then send the corrected claim to insurance by updating the correct dx code.
• If the coding team states that the dx code is correct then send an appeal to insurance.

44. Claim Denied for New Patient Code Exceeded OR Payment adjusted because “new patient” qualifications were not met: (Adjustment reason code: B16)

1. A new patient code can only be billed 3 years once if that particular patient is not visiting the same doctor or group
2. When the rep states a new patient code was exceeded, ask when did this patient last visit to this provider or group

(Check in the billing summary whether any DOS was billed previously within the last 3 years’ time frame under the same tax id or same provider.) If yes ask the below question

3. May I get the corrected claim mailing address with a timely filing limit
4. If no previous DOS billed within the last 3 years time frame then clarify with a rep and send to reprocess
5. Claim #?
6. Call reference #?

End action:  

• Send to the coding team to review and provide the correct CPT code and once a response is received with correct CPT details then send the corrected claim to insurance by updating the correct CPT code.

45. Claim denied for missing medical records or is not clear:

(Adjustment reason code: B12)

1. 1. Medical records submitted is not clear or legible, If any pages missing or don’t match with the submitted claim
2.  Open and check the document in the attachment
3. Get the mailing address where the clear records need to be sent
4. Timely filing limit?
5. Claim#?
6. Call reference#?

End action:  

• Send the  medical records to the address given by the rep 
• If no medical records are found in attachments then assign them to client assistance.

46. Claim denied for Referring provider information Missing Or Invalid: 

(Adjustment reason code: N265)

1. Referring to provider information available in our claim doesn’t match with the payer system Or the Information is missing
2. Get the correct PCP name and contact number
3. Corrected claim mailing address and timely filing limit?
4. Claim#?
5. Call reference #?

End action:  

• Assign to client assistance to get the Referral from PCP
• PPO & EPO plan does not require a patient to visit a referring physician, so referral is not required whereas in HMO & POS plan, it is necessary to visit a referring doctor, so referral# is required.

47. Primary EOB missing OR  Secondary payment cannot be considered without the identity of or payment information from the primary payer:

(Adjustment reason code: MA04)

1. Calling primary payer but the denial is primary EOB
2. Check in the billing summary and find whether the same payer has paid any previous claim as primary
3. If yes then cross verify on the same
4. If no ask who is the primary payer as per the record
5. Claim #?
6. Call reference#?

End action:  

• When the rep provides all details of primary insurance then you can update that insurance as primary and make current insurance as secondary insurance and resubmit the claim to primary insurance.
• If the rep does not provide primary insurance details then checked in the system if there is any other insurance available or patient payment history has any other insurance as primary, if yes then check eligibility for that insurance and resubmit the claim to that payer if the policy is active as primary or else release the claim to the patient if the policy is inactive or no other insurance information available.

48. Claim  denied for Invalid CPT : 

(Adjustment reason code: 181)

1. Denied date
2. Check in the claims history and see whether the denied CPT is paid before in any date of service by the same payer
3. If it was paid cross verify with the rep that on the previous date of service the same code got paid.
4. If it was not paid, get the corrected claim mailing address with the timely filing limit
5. Claim#?
6. Call reference#?

End action:

• Check payment history, If the same CPT was already paid on another DOS then verify with the rep and reprocess
• If no payment was found previously on this CPT code then send it to the coding team to find the correct CPT once the coding team updates with the new CPT code then resubmit it to the payer

49. Claim denied for Duplicate:

(Adjustment reason code: 18)

How duplicates happen: If two claims are submitted with the same information like (Same DX, CPT, MODIFIER, BILLED AMOUNT, PROVIDER information, etc,).  If any one of these details is differing then you can inform the differences to the rep and ask to reprocess the duplicate claim.

1. May I know claim received date?
2. May I know claim denied date?
3. First, ask the rep “may I know whether this claim was received as a new claim or a corrected claim”? (mostly it will come as a new claim then the denial is correct, suppose if the rep checked and found it was received as a corrected claim then the denial is incorrect so ask the rep to reprocess)
4. Could You please send this claim for reprocessing since we have submitted the claim as a corrected claim? (If the rep agrees ask the below question)
5. May I know the reprocessing time? then claim# & call reference#?
6. If the claim was submitted as a new claim then verify with the rep whether all these details are the same or not (DX, CPT, MODIFIER, BILLED AMOUNT, PROVIDER information, etc),
7. Could you verify the diagnosis code, CPT code, modifier, and provider name that you have in your system
8. If any of the above details are different then ask to reprocess,
9. Could You please send this claim for reprocessing since I have a different dx code or CPT code or provider name? (If the rep agrees ask the below question)
10. May I know the reprocessing time? then claim# & call reference#?
11. If the above details are the same then ask about the original claim status
12. May I get the original claim status?
13. Get both Original Claim# and Duplicate claim# and then
14. Call reference#?

End action:

• If two claims are submitted to insurance with the same claim information.
• AR caller needs to call insurance and verify whether the claim was received with the same information or not.
• If the same claim was submitted twice need to write off/adjust the duplicate claim
• If the original claim was paid then get the paid status, if it is in the process then allow some more days, if it is denied for some other reason then question that specific denial scenario.