Basic denials requiring corrections:
Incorrect id # - This may be due to the following: (a) the source document may have an incorrect id. (b) data entry error (c) the id format may not be in the billing rule. If the denial is due to (a), then we need to document such denials and notify the client immediately. If the denial is due to (b), we need to find out where the breakdown is and why this has escaped the eyes of the charge entry person and audit. If the denial is due to (c) i.e. if the id # entered is not in proper format, then we need to immediately trap this kind of error for other claims also and we can correct the claim before sending it out in the first place.
Incorrect or No modifier – This may be due to two situations: (a) the ignorance of the charge entry person as to what modifier should be applied for the particular procedure and (b) data entry error. In either case proper guidelines should be set such that for these procedures this modifier should be used, then any charge without that modifier should not be generated as a claim and transmit to the insurance.
Coverage not valid for DOS - Coverage Terminated; Benefits Exhausted – These are patient related. However if we had the effective dates of each coverage established, then the first two kinds of errors can be identified at the front end itself before the claims are generated. As regards the last one i.e. Benefits exhausted, this may be due to the fact that the patient’s policy will pay for a particular procedure only once during a year or once during a life time or the insurance company’s general rules for a particular procedure may be only once reimbursable. If it is patient policy specific, then this can be known only when we receive the denial. The ultimate solution for all these cases is to bill the patient.
Non-covered services – The member’s policy does not cover the service provided. Here also we can bill the patient. However we cannot bill a Medicaid patient for this denial in certain states.
Unable to identify patient – This may be due to two things: (a) the coverage details given in source document may be incorrect and (b) data entry error. If this is due to the latter, it may be due to the fact that the operator has entered the patient name or the id # or the insurance company number incorrectly. We should correct this and resubmit the claim immediately. If it is due to the former, then such errors need to be documented and notified to the client. However follow up needs to be done to correct the claim and resubmit.
Require medical records or Denied for Medical Necessity – In the first opinion of the carrier, they may feel that the procedure may not be necessary for the diagnosis specified. Hence the request for medical records. We should pull out the medical records from the charge file, take copies of it, attach it along with the claim with a covering letter and send it. Analysis should be done to resubmit all claims with the given procedure-diagnosis combination for the insurance carrier with medical records.
Applied to deductible – The patient would not have met his deductible for the year. Hence the carriers would adjust the deductible due from the amounts payable to the provider for the patient account. Since deductible is the patient’s responsibility, we need to bill the patient for the amount applied to deductible.