The Importance of AR Follow-Up in Medical Billing

In the complex world of medical billing, Accounts Receivable (AR) follow-up is a critical component that often goes overlooked. Effective AR follow-up ensures that your practice maintains a steady cash flow and maximizes revenue. At Reliable Billing Solutions, we specialize in providing comprehensive AR follow-up services to help your practice thrive.

What is AR Follow-Up?
AR follow-up involves diligently tracking and resolving outstanding claims and unpaid balances with insurance companies and patients. This process is essential for maintaining the financial health of your healthcare practice.

Why is AR Follow-Up Important?
Financial Stability: Consistent AR follow-up ensures a steady flow of funds, which is crucial for covering operational expenses and providing quality patient care.

Claim Resolution: Timely follow-up helps in resolving denied or delayed claims, ensuring that you receive rightful reimbursements.

Reduced Delinquencies: Proactive follow-up minimizes the risk of unpaid invoices, which can accumulate and impact your practice’s financial health.

Improved Cash Flow: Effective AR follow-up accelerates the payment process, leading to improved cash flow and financial stability.

Steps for Effective AR Follow-Up
Streamline Your Billing Process: Ensure accurate charge entry, thorough documentation, and precise coding to avoid claim denials and delays.

Verify Insurance Information: Conduct comprehensive insurance verification before providing services to avoid claim rejections.

Timely Submission of Claims: Submit claims within 24 to 48 hours of service delivery to expedite the reimbursement process.

Regular Monitoring: Continuously monitor the status of claims and follow up on any outstanding balances.

Effective Communication: Maintain clear and consistent communication with insurance companies and patients to resolve issues promptly.

How Reliable Billing Solutions Can Help
At Reliable Billing Solutions, we offer expert AR follow-up services to help you manage your accounts receivable efficiently. Our team of skilled professionals is dedicated to ensuring that your claims are processed accurately and promptly, maximizing your revenue and reducing administrative burden.

Conclusion
AR follow-up is a vital aspect of medical billing that directly impacts the financial health of your practice. By implementing effective AR follow-up strategies and partnering with Reliable Billing Solutions, you can achieve better financial outcomes and provide superior patient care.

Transcript

1. MEDICAL BILLING NOTES ABN- Advanced Beneficiary Notes: An ABN is a written notice from Medicare (standard government form CMS-R-131), given to patient before receiving certain items or services, notifying patient that Medicare may deny payment for that specific procedure or treatment. AMA- American Medical Association: AMA main mission is to improve the nation health by bringing providers together. AGING: It refers to unpaid insurance claim for past 30 days. Allowed Amount: Allowed amount is the amount allowed by the insurance towards each and every service. Appeal: Provider or patient can object the decision of the claim along with complete documentation, when an insurance plan does not pay the claim. AOB- Assignments of Benefits: It’s an agreement, when signing an AOB agreement, patient agree to allow the medical provider to seek payment from your health insurance company directly. Beneficiary: It defines a person or persons covered by health insurance plan. Billed Amount: It is the amount that the provider bills for the service rendered by him and is entered by the billing office at the time of charge entry. Billed Amount = Allowed Amount – Write off.
2. Balance Billing: When a provider bills you for the difference between the provider's charge and the allowed amount. For example, if the provider's charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Capitation: A fixed amount paid by insurance company to the providers over a period of time for patient’s healthcare services. It means contracted providers who accept capitation will receive a bulk payment (like a salary). CHAMPUS- Civilian Health and Medical Program of the Uniformed Services: CHAMPUS or TRICARE is a military health care program for members on active duty and retired members of the uniformed services, their families, dependents, and survivors. CMS- Centers for Medicare and Medicaid Services: It’s an HCFA form that is use for submission paper claim. Authorization Number: To be obtained by the provider before certain medical services are rendered to the patient. Beneficiary Eligibility Verification: A way for doctors and hospitals to get information about the patient’s insurance coverage / benefits. CDM- Charge description master: A master file of charges listing charge amounts for procedure codes. Coinsurance: A percentage the patient is responsible to pay the cost of the medical services. Co-pay: The amount an insured person is expected to pay for a medical expense at the time of the visit. Collection Agency: A business that collects money for unpaid bills.
3. Contractual Adjustment: The part of the bill that doctor or hospital must write off (not charge patient) because of billing agreements with patient’s insurance company. Coordination of Benefits (COB): A way to decide which insurance company is responsible for payment if patient has more than one insurance plan. Deductible: A fixed dollar amount that insured person has to pay before insurance plan start. Durable Medical Equipment (DME): Medical equipment ordered by the doctor, usually for use at home. Emergency Care: Care given for a medical emergency when the patient's health is in serious danger. Guarantor / Subscriber / Policy holder / Insured: A person who is covered by health insurance. Explanation of Benefits / Remittance advice (EOB/ERA): The notice sent to the patient and the doctor from patient's insurance company after processing claims explaining the status. Exclusions: Specific conditions or circumstances for which the policy will not provide benefits. Federal Tax ID Number: A number assigned by the federal government to doctors and hospitals for tax purposes. Fee schedule: A listing of the reimbursement that an insurer or health plan will pay for a service based on the CPT code. Global Days: The period of time that begins up to 24 hours before a surgical procedure starts. HCPCS: a coding system used to report procedures, services, supplies, medicine, and durable medical equipment. HCPCS modifier: a two-character alphabetic or alphanumeric descriptor used with CPT level I and level II national codes.
4. HIPAA: Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of health information. HMO (Health Maintenance Organization): With an HMO plan, you must stay within your network of providers to receive coverage. In Network: Those providers who accepts the health insurance plan policy. . Inpatient (IP): A patient who has been admitted to a hospital and stays 24 hours or more. Insurance company – An organization contracted with patient to pay for his health care expenses. Also known as insurer. Insured: One who is covered by an insurance policy. Insured Group Name – Name of the group or insurance plan that insures the patient. Insured Group Number: A number that your insurance company uses to identify the group under which the patient is insured. Internal Control Number (ICN) / Document Control Number (DCN): A number assigned to the bill by the insurance company or their agent. Itemized statement: An itemized statement provides a complete listing or detailed account of every service posted to a patient account. Limited Policy: A policy that covers only specified accidents or illnesses. Lockbox: A banking term used when a physician or hospital has their insurance checks deposited directly into their bank account. Managed Care: Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care. MRN- Medical Record Number: The number assigned by a doctor or hospital that identifies an individual medical record.
5. Mother Baby clause: Mother Baby clause is a rule in which a newborn baby is covered under the policy of the mother for a period of 30 days from the date of birth. Medical Necessity: Medical information justifying that the service provided is reasonable and appropriate for the diagnosis. Medically Necessary: Many insurance policies will pay only for treatment that is deemed "medically necessary" to restore a person's health. For instance, many health insurance policies will not cover routine physical exams or plastic surgery for cosmetic purposes. Modifier: A modifier provides the additional information with CPT. National Provider Identifier (NPI): An NPI number, known as a National Provider Identifier, is a unique identification number issued to each healthcare provider. Non-Covered Charges: Service or procedure not listed as a covered benefit in insurance plan. These may or may not be billable to the patient. Non-Participating Provider (out of network provider): A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or hospital network. Observation: No more and no less than 23 hours. Type of service used by doctors and hospitals to decide whether the patient needs inpatient hospital care or can recover at home or in an outpatient area. Out-of-Pocket Costs: The patient’s share of the cost of health care services. This can include co-payment, co- insurance, or deductible. Outpatient (OP): When the patient stays less than 24 hours and is not admitted to the facility. Over-the-Counter Drug: Drugs not needing a prescription that can be bought at a pharmacy or drug store. Offset: When an insurance company makes a wrong payment to its providers, it would adjust the amount in its subsequent claims. This is called an offset.
6. Place of Service – This designates where the actual health services are being performed, example: hospital, office skilled nursing facility. Policy Number / Member identification number / HIC number (Medicare): A number the insurance company gives the policy holder to identify the contract. Point-of-Service (POS) Plan – A plan offered by managed care. The primary care doctors usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still have coverage. PPO (Preferred Provider Organization): You can use doctors, hospitals, and providers outside of the network for an additional cost. Precertification: Authorization for a specific medical procedure before it is done. Pre-Existing Condition: A health condition or a medical problem the insured has before signing up to receive insurance coverage. Some health insurers may not pay for these health conditions. Primary Insurance Company: The insurance company who is responsible for paying the claim first. If patient has another insurance company, it is referred to as the Secondary Insurance Company. Provider Identification Number (PIN): Assigned by the Insurance company to their contracted providers. Rebill: To resubmit a claim. Referral: Permission from the primary care physician to seek services from a specialist for an evaluation, testing, and/or treatment. Managed care plans require this. Release of Information (ROI): A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims. Secondary Insurance: The insurance plan that is billed after the primary has paid. Superbill: A form listing procedures and diagnosis codes used to record services performed for the patient and the patient’s diagnosis for a given visit.
7. Supplemental: Another name for secondary insurance. A supplemental plan usually picks up the patient’s deductible and/or co-insurance. Timely filing limit: The time frame that payers give to providers to submit the claims. UB 04: A form used by hospitals to file insurance claims for medical services. UCR (Usual and customary rate): It’s an out-of-pocket fee that a health insurance policyholder must pay for services. UCR fees are based on the services provided to policyholders, as well as the area of the country where the services are being provided. Utilization Review (UR): A retrospective review of treatments or services that have already been administered. V Codes: ICD-9(diagnosis) code assigned for preventive medicine services and for reasons other than disease or injuries. Write Off: A provider write-off is the amount eliminated from the fees for a service provided by a facility that serves as a healthcare provider for an insurance company. W-9 Form: A tax form which certifies an individual's tax identification number. Crossover Claim: When a person eligible for Medicare and Medicaid receives health care services covered by both programs. Day Sheet: A page that lists all health care procedures, payments, and adjustments for a single day. Demographic: Demographic entry is the basic information of the patient filled in the health insurance claim. EFT- Electronic Funds Transfer: Electronic funds transfer (EFT) transmits funds for claims payments directly from a health plan into your bank account. EMR- Electronic Medical Record: It is a digital version of a patient's chart. It contains the patient's medical and treatment history from one practice.
8. EHR: An EHR contains the patient's records from multiple doctors and provides a more holistic, long-term view of a patient's health. GPH: Group health plans provide coverage to a group of members, usually comprised of company employees or members of an organization. Health Care Reform Act: Make affordable health insurance available to more people. Indemnity: Indemnity plans allow you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. IPA- Independent Practice Association: An IPA is a type of HMO in which healthcare services are provided by independent physicians who contract with the HMO under the insurance plan. Telemedicine: Getting the health care service through telecommunication. Place of service code is 2 with GT or 95 modifiers are used. Modifier CS: In case of covid 19 testing, modifier instruct to resubmit with CS Receive 100% payment. Taxonomy Code: Identifying area of specialization. Pre-Authorization: Obtaining permission to perform a service from insurance before service is performed.
9. Retro Authorization: Retro as opposed to prior auth is when you have to go back after a procedure is performed and try to get the authorization granted so the provider gets paid. NCCI- National Correct Coding Initiative: To promote national correct coding methodology and to control improper coding which leads to impropriate payment in Part B. Unbundling: Billing separately for multiple components of a procedure that should be as a single charge. QMB- Qualified Medicare Beneficiary: The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries Intensive Care: Intensive care units (ICUs) are areas of the hospital where seriously ill patients receive specialized care such as intensive monitoring and advanced life support. MSP- Medicare Secondary Payer: Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. Pre-Determination: A review process conducted by the health plan to determine if services are medically necessary and covered under the policy. Worker Compensation: Worker compensation are provided by carriers to employers to cover treatment for illness or injuries that happen to their worker. Rendered Physician: Who performed the service or rendered the service.
10. PHI- Protected Health Information: individually identifiable health information. PTAN- Provider Transection Access Number: The Provider Transaction Access Number (PTAN) is a Medicare-issued number given to providers upon enrollment with Medicare. This number is usually six digits and is assigned based on the type of service and the location of the provider. Skilled Nursing Facility: A skilled nursing facility is an in-patient rehabilitation and medical treatment center staffed with trained medical professionals. They provide the medically-necessary services. SSN- Social Security Number: Social Security number (SSN) is a nine-digit number issued to U.S. citizens, permanent residents, and temporary (working) residents. Term date: Term date is the date the insurance policy is expired or ended. Tertiary Insurance: It is also called as third insurance policy, which covers the claim after primary and secondary insurance policy. It is useful to fill the gaps in cover. TPN- Third Party Administrator: Third Party Administrator is an independent corporate entity or person, who administers group benefits, claims and administration for a self-insured company or group. Locum Tenens: Locum tenens are contracted physicians who substitute for a physician who has left the practice, or who is temporarily unavailable. Supervision Provider: The Supervising Provider is the individual who provided oversight of the Rendering Provider and the care being reported.
11. HITECH- Health Information Technology for Economic and Clinical Health Act: The HITECH Act encouraged healthcare providers to adopt electronic health records and improved privacy and security protections for healthcare data. Dormant Balance: Dormant is a state of rest or inactivity. If the balance remains unpaid for a certain defined time period, it is referred as dormant balance. Max Out of Pocket: Max out of pocket is the limit, on the amount of money you have to pay for covered health care services in a plan year. If you meet that limit, your health plan will pay 100% of all covered health care costs for the rest of the plan year. Interactive Voice Response (IVR): Computerized Recorded Voice. Billing Provisions: The medical billing process is a process that involves a 3rd party payer, which can be an insurance company or the patient. Medical billing results in claims. The claims are billing invoices for medical services rendered to patients, After the doctor sees the patient, the diagnosis and procedure codes are assigned. Pointers: Pointers are used to indicate the appropriate order of importance in relation to the service being performed. NDC- National Drug Code: It is a unique, 3-segment numeric identifier assigned to each medication. he first segment of the NDC identifies the labeler. The second segment identifies the product and the third identifies the package type and size. CLIA- Clinical Laboratory Improvement Amendment: The Clinical Laboratory Improvement Amendments (CLIA) regulate laboratory testing and require clinical laboratories to be certified by the Center for Medicare and Medicaid Services (CMS) before they can accept human samples for diagnostic testing.
12. Applied To Deductible: A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn't cover. Medicare Part A to D: Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income. Part A: (Hospital Services) In Patient Care, Bed Charges, Equipment Charges, Hospice and Home Health Care. Part B: Out Patient Services. Part C: Medicare Advantage Plan, Part A and Part B Includes. Part D: Drug Program Credentialing: This is an application process for a provider to participate with an insurance carrier and an intensive process whereby the insurance company conducts a background check on the physician. CAQH- Council for Affordable Quality Healthcare: Council for Affordable Quality Healthcare, allows insurance companies to use a single, uniform application for credentialing. Hospice: Hospice is a special way of caring for people who are terminally ill. Claim Acknowledgement: The purpose of the 277CA (Claims Acknowledgement) transaction is to provide a claim level acknowledgement of all claims received in the pre-processing system before submitting claims into a payer's adjudication system. FTP- File Transfer Protocol: A standard protocol for exchanging files between computers on the Internet.
13. CPT Codes: Current Procedural Terminology. Category 1: CPT codes are used for reporting devices and drugs (including vaccines) required for the performance of a service. Like 1000 to 99999. Category 2: These codes provide the data needed by the Performance Measures Advisory Group (PMAG). Like 0500F or 7025F. Category 3: Category III CPT codes are used for reporting emerging technology in a number of capacities including services or procedures recently performed on humans, clinical trials and etc. Like Emerging Technology 0016T-0207T. Incident To Provision: In “Incident To” provision of Medicare, services are submitted under the physician’s NPI but are actually performed by Non-Physician practitioners such as; Nurse Practitioners (NP), Physician Assistants (PA), Registered Nurses or other qualified technicians. Billing Protocol: ▪ Non-Physician Practitioners, “Physician Assistant” or “Nurse Practitioner” will be selected “Attending Physician”. ▪ Physician (MD) will be selected as “Billing” and “Supervising” Physician. ▪ There are no modifiers that signify a service was provided “Incident To”. Payment: Payment is made at the 100% of the Medicare Physician Fee Schedule General Supervision: If “Incident To” requirements are not met, the service must be billed under the Non-Physician Practitioner’s own NPI, it is known as “General Supervision. Billing Protocol: Physician Assistant” or “Nurse Practitioner” will be selected as “Attending” and “Billing” Physician Supervising Physician” is not required in General Supervision. Payment: In General Supervision, the Nurse Practitioner is paid for covered services at 85% of the Medicare Physician Fee Schedule.
14. Practice Management Software: Medical practice management systems help physicians and their staff record patient demographics, manage charge capture, perform billing. Follow Up (AR): Steps: First step of follow up is to find out the reason why the claim is pending. Check the current status of the claim through available resources like web portal, interactive voice response (IVR), fax or live call. 1- Web Portal: is an efficient source of follow up which is an online to find out eligibility, benefits and claim status. It requires a user name and password that is used to log in to the portal 2- Interactive voice response (IVR): is a technology that allows a computer to interact with humans through the use of voice input via phone keypad. It also facilitates to check eligibility and claim status. 3- Live call: should be last option to be used for follow up activity. However, telephonic appeals and claim review require interaction with a live representative. 4- Fax: option may be used to request status of a claim or to request a copy of an EOB. Rail Road: The Medicare insurance program covers railroad working personals like a workers under social security of other departments. Practice Information: Practice Name: RWJ Practice Code: 6710045 Practice Special: Multiple Practice Location: Multiple Location Practice Providers: Multiple Providers Pricing & Non-Pricing Modifiers: A pricing modifier is a medical coding modifier that causes a pricing change for the code reported and a non-pricing modifier is a medical coding modifier that do not causes a pricing change for the code reported.
15. Upcoding & Down Coding: A hospital bills the payer using CPT code for a more expensive service then was performed. A hospital bills the payer using CPT code for a less expensive service then was performed. New Patient: A patient who did not receive any professional services within past three years.99201 to 99205. Established Patient: A patient who received the professional services within past three years.99211 to 99215. Double Billing: This happens when the same bill is submitted multiple times when the procedure was performed only once. Duplicate Billing: Any claim submitted by a physician or provider for the same service provided to a particular individual on a specified date of service. CPT Codes: • 00100-01999. Anesthesia. • 10004-69990. Surgery. • 70010-79999. Radiology Procedures. • 0001U-89398. Pathology and Laboratory Procedures. • 90281-99607. Medicine Services and Procedures. • 99091-99499. Evaluation and Management Services. • 0001F-9007F. Category II Codes. • 0002M-0017M. Multianalyte Assay. HCFA Form Boxes: 1-Payer Name, 2-Patient First & Last Name, 3-DOB & Gender, 4-Subscriber Information, 5- Address Information, 6-Relationship to Subscriber, 7-Subscriber Address Information (in case not self), 8-NUCC Used, 9- Secondary Insurance Information, 11-Insurance Group Number, 12-Patient Signature, 13-For Auto Accident, 17-Refering Prover Information, 21- ICD-10 Codes, 22-Claim Type and ID of Original Claim, 23-Pre Authorization, 24-Procedure Code, 25-Tax ID, 26-Patient Account Number, 27-Insurance Setup, 28-Total Charge, 29- Patient Payment, 30-NUCC Used, 31-Provider Name, 32-Offfice Name & Address, 33- Adress of Billing Provider.
16. Modifiers GQ- Modifier GQ is used to code for services delivered via an asynchronous telecommunications system. GT or 95- Modifier 95 can be used to code all of the diagnosis, evaluation, or treatment of symptoms via Telemedicine. TC- Technical Component QW- The diagnostic lab service. GV- Services provided by an attending physician not employed or paid by the patient's hospice provider. GX- a voluntary Advance Beneficiary Notice of Noncoverage (ABN) FP- Family planning services AI- The principal physician of record during an inpatient admission TA- Left foot, great toe T1- Left foot, 2nd digit, T4- Left 5th digit, T5- Right foot, great toe, T9- Right foot, 5th digit. FA- Left hand, thumb F1- Left hand, 2nd digit, F4- Left hand 5th digit, F5- Right hand thumb, F9- Right hand,5th digit. P1- a normal, healthy patient. P2- a patient with mild systemic disease. P3- a patient with severe systemic disease. P4- a patient with severe systemic disease that is a constant threat to life 59- Modifier 59 is used to identify procedures/services, other than E/M services. XE- Separate Encounter, XS- Separate Structure, XP- Separate Practitioners, XL- Unusual Non-Overlapping Service. 25- Report an E/M service on a day when another service was provided to the patient by the same physician. 26- Professional Components. Report view, test view, x-ray view. Not perform service. 76- When the repeated E/M perform by the same physician on the same day. 77- When the repeated E/M perform by the different physician on the same day. 22- Modifier 22 is used for increased procedural services. 62- Two surgeons perform service on a same patient during operation. 80- 82 Represents assistant at surgery by another physician 90- Laboratory procedures.
17. 24- Modifier 24 is appended to unrelated evaluation or management (Unrelated E/M) service offered during the post-operative period of a major surgery performed within 90 days by the same physician. This modifier cannot be used to bill for procedures. G0- Modifier G0 is used to code for telehealth services offered to diagnose or treat the symptoms of an acute stroke 51- Modifier 51 is used to bill for multiple procedures or surgeries offered by the same provider during the same surgical session. Diagnostic imaging services provided during the surgical session is also included. DENIALS CO 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing. Determine coding team which of the modifier is actually describing the performed services, Ensure the necessary, appropriate modifiers are appended in the claim, resubmit the claim. CO 5 - The procedure code/bill type is inconsistent with the place of service. Check the POS and CPT combination. Resubmit the claim. CO 8 - The procedure code is inconsistent with the provider specialty. CO 11 - The diagnosis is inconsistent with the procedure. Contact with provider for the correct CPT. CO 15 - Payment adjusted because the submitted authorization number is missing, invalid, or does not apply to the billed services or provider. CO 16 - Claim/service lacks information. See the explanation of additional remark code(s) on the ERA under the code 16 for further information that what type of information is requested for claim processing, If the additional remark code(s) is not provided, one should call insurance to get the information needed to resubmit the claim, Provide/attach/append/rectify claim information accordingly and re-file claim.
18. CO 18 - Duplicate claim has already been submitted and processed. Fix the claim and resubmit with the correct information or appeal the original decision with additional information. CO 20-21 -This injury/illness is the liability of the no-fault carrier. Check the DX. IF the patient has work related or accident related injury, then this claim should submitted to WC or No Fault insurance. Or change the DX and submit the claim. CO 22-23 - Payment adjusted because this care may be covered by another payer per coordination of benefits. Verify plan’s eligibility and consult COB section to confirm primary insurance. Ensure that the correct primary insurance for the patient has been billed. CO 24 - Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan. Check either your practice/provider is in capitation agreement with payer, if yes adjust the claim with adjustment code 24, if no, generate call for reprocessing. CO 26 - Expenses incurred prior to coverage. CO 27 - Expenses incurred after coverage terminated. CO 29 - The time limit for filing has expired. If you have submitted the claim within the timely filing limit then appeal the claim with required proof. Or no other way just write off the claim. CO 31 - Claim denied as patient cannot be identified as our insured. Check patient’s eligibility through real time or obtain through insurance website to make sure information submitted is correct and there is no mismatch, In case of any conflict, correct the information and resubmit claim, If all seems correct, one should generate call for insurance to review the claim. CO 45 - Charges exceed your contracted/legislated fee arrangement.
19. CO 50 - Treatment provided was not medically necessary. First check if DX matched with CPT code if yes then provide medical notes to the insurance company. CO 96 - Non-Covered Charges. Reason- The patient availed services that were not covered in his/her insurance plan If non-covered in the patient’s plan, bill to the patient with reason code 02 – Non-Covered benefits. CO 97 - Procedure or Service Isn't Paid for Separately. Denial Code CO 97 occurs because the benefit for the service or procedure is included in the allowance or payment for another procedure or service that has already been adjudicated. CO 109 - Claim not covered by this payer/contractor. Verify the patient’s eligibility for correct payer confirmation, Consult with provider for confirmation of insurance information. If correct insurance information is not confirmed, bill to patient with the rejection type 16 - covered by another payer. CO 119 - Item has met maximum limit for this time period. Payment already made for same/similar procedure within set time frame. CO 197 - Precertification/authorization/notification/pre- treatment absent No valid authorization. In this case we can bill to patient using rejection type IA i.e. invalid authorization. We can receive this denial because of wrong usage of PA # or not used on claim level. CO 204 - This service/equipment/drug is not covered under the patient current benefit plan Need to bill the patient if the services are not covered under patient plan. CO 236 - procedure/modifier combination is not compatible with another procedure or procedure/modifier combination. CO 234 - Not Paid Separately.
20. CO 252 - An attachment is required to adjudicate this claim/service Review patient’s account/claims to see if the submitted information is correct, further clarify which information is required, insurance call can be helpful, attach/provide requested information/documentation and resubmit the claim. CO 288 - Referral absent. CO 287 - Referral Exceeded. A1 - Claim/Service denied. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) B 7 - This provider was not certified/eligible to be paid for this- procedure/service on this date of service. B 15 - Payment adjusted because this procedure/service is not paid separately. If it is a separate/distinct service, appropriate modifier is used to denote as a separate service for reimbursement, medical notes may also support to prove the Medical Necessity. B 20 - Procedure/service was partially or fully furnished by another provider. ALL ACTIONS AGAINST THE DENAIL: • Reprocessing a claim • Contact / bill patient • Claim rebill / appeal • Review and write off • Follow-up with the same or another payor.