Claim rejected as Duplicated claim - What are the possible ways to find outcome?

Q: My claim rejected, or was returned to provider, as a duplicate of another claim. Can I resubmit the claim? What steps can I take to avoid duplicate claims?

A: Claim system edits are in place to detect duplicate services. The edits search within paid, finalized, pending, and same claim details in history. This means that unless applicable modifiers and/or condition codes are included in your claim, the edits detect duplicate and repeat services within the same claim, and/or based on a previously submitted claim.

The following reject reason codes are commonly seen with this edit:
• 38005 -- This claim is a duplicate of a previously submitted inpatient claim
• 38031 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim
• 38035 -- This outpatient claim is a possible duplicate to a previously submitted outpatient claim for the same provider
• 38038 – This claim is a possible duplicate of a previously submitted claim
• 38200 -- This is an exact duplicate of a previously submitted claim

The following return to provider (RTP) reason codes are commonly seen with this edit:
• 38032 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim
• 38037 -- This outpatient claim is a duplicate of a previously processed or submitted outpatient claim

Your claim rejected as a duplicate, because one or more of the following items matched the original claim:

• Health Insurance Claim Number (HICN), provider number, type of bill (TOB)--all three positions of any TOB, statement coverage from and through dates, at least one diagnosis or line item date of service, revenue code, HCPCS code, and/or total charges (0001 revenue line).

To prevent duplicate claims, verify status of claim prior to filing.

1. If you use direct data entry (DDE) pdf file, access the beneficiary's HIC number to verify the history of claims submitted and the status/location of those claims. Note: you cannot see claims submitted by other facilities.
2. Check status of claims via the Secure Provider Online Tool (SPOT).
3. Contact the interactive voice response (IVR) pdf file system by calling (877) 602-8816. There are three breakdowns available: claim status, return to provider and pending claims.
4. Review the remittance advice for the history of the beneficiary's claims.

In addition, if your claim includes repeat services or supplies, append modifiers and/or condition codes, as applicable. For a complete list of coding resources, refer to the Medicare Billing: 837I and Form CMS-1450 Fact Sheet external pdf file

If you submit claims via the electronic data interchange (EDI) gateway, you are provided with confirmation when the batch of claims is received. Please wait for this confirmation, instead of resubmitting the batch of claims. If you make one change to one claim in the batch but resubmit the entire batch, all the claims go to the fiscal intermediary shared system (FISS), resulting in duplicate claims. Do not resubmit the entire batch; resubmit corrected claims only.

Note: If a third party vendor, billing service, or clearinghouse submits claims on your behalf, contact them to ensure they are not resubmitting entire batches of claims as described above. In addition, occasional software glitches can cause the resubmittal of an entire batch. Be aware that these software or vendor issues reflect directly upon the provider and are problematic, at best, and considered possible abuse, at worst.

Listed below are some recommendations, when additional action is required to correct your claim(s):
• You have two options when the original processed claim needs to be updated or corrected.
1. Adjust the original processed claim (TOB xx7) and resubmit.
2. Cancel the original processed claim (TOB xx8) and submit a new claim, but you must wait for the cancelled claim to finalize before the new claim is submitted.
• If two claims were submitted at the same time and resulted in duplicates against each other, submit a new claim.
• If the rejected claim is an exact duplicate to a previously processed/finalized claim, no action is necessary.

How to resolve when denial received on two provider submitting on DOS ?

My inpatient claim is overlapping a home health episode with the same date(s) of service. How can I resolve this?

A: Claims for inpatient hospital and skilled nursing facility (SNF) services have priority over claims for home health services, as beneficiaries cannot receive home care while they are institutionalized. Beneficiaries cannot be institutionalized and receive home care simultaneously.
• Verify dates of service on your claim
• If dates of service are incorrect, correct your claim and resubmit.
• If dates of service are correct, it is recommended that you contact the home health agency and ask them to correct their claim.
• Edit exclusions:
• The inpatient claim admission date is the same as the home health agency transfer/discharge date
• The inpatient claim discharge date is the same as the home health agency admission date
• The inpatient claim dates are between the occurrence span code 74 ‘From’ date and the day following the occurrence span code ‘Through’ date


Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Q: How do I bill my claims when a patient revokes or elects hospice coverage during his/her inpatient stay?
A: Electing or revoking the Medicare hospice benefit is the beneficiary’s choice. The patient or his/her representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary’s election, nor request or demand that the patient revoke his/her election. If the patient revokes his/her hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the traditional Medicare program. The information below provides a general guidance on how to submit claims.
When a beneficiary elects hospice during an inpatient stay:
• Bill traditional Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a patient revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill traditional Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement from date is the same as the hospice revocation date

Common Error that results Denial - Molina Healthcare

Errors That Result In Denied Claims;

This information is presented for you to review your internal procedures and identify areas where the number of denied claims could be reduced. Denied claims result in delay of payment. Please note HIPAA claim adjustment reason and remit remark codes as provided on the remittance advice.

Claim Errors (Remittance Advice Remarks)

• The rendering provider is not eligible to perform the service billed (185) or claim/service lacks information which is needed for adjudication. (16/MA30)

o Service code not covered to the provider type or specialty

Note: If a procedure code is not covered, the provider will need to submit documentation for review to Molina per the following:

• The request must submitted in writing

• The request must be supported with documentation

o documentation should include any claim examples or indicate why the code should be payable

• If there is no supporting documentation, the request will not be considered.

• Missing/incomplete/invalid HCPCS Code (A1/M20)

o Validate code keyed correctly

o Validate code is current for Date of Service (DOS)

• Missing/incomplete/invalid/deactivated/withdrawn National Drug Code (NDC) (16/M119)

o For resolution to these denials, please refer to www.dhhr.wv.gov/bms

----Select Drug Code/NDC Drug Information.

o NDC, unit of measure and units should be submitted on Medicare primary claims (even though not required by Medicare) so the information will cross over to Medicaid, eliminating the need to submit Medicaid secondary -claims on paper.

How to avoid denial CO/PR B7 CO 97 Remark Code - M15, M144

Denial reason code CO/PR B7

We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?

Provider was not certified/eligible to be paid for this procedure/service on this date of service.

You received this denial, because the date of service on the claim is prior to the provider’s Medicare effective date, or after his/her termination date, or because you are billing for a procedure code beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or the laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.

• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.

• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. 

Note: The effective date can be retroactive, 30 days from receipt of application, or for a future date of up to 60 days after receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.

Submit claims for laboratory services within the scope of the provider’s CLIA certification.

• Verify service/procedure code is listed as approved under the scope of the provider’s certification. 

• Refer to the complete list of downloads of Categorization of Tests on the Centers for Medicare & Medicaid Services (CMS) website. 

• Refer to the List of Waived Tests from the CMS website to determine which codes require the modifier QW (CLIA waived tests).

• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.

Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.

Or, if applicable, request a telephone reopening. Note: The First Coast Service Options Part B interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.

Denial reason code CO 97 

We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?

The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below, as applicable, to avoid this denial.

Diagnostic Tests- CMS Requirements - Medicare denial

The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of diagnostic tests due to missing physician/non-physician practitioner order or intent within the medical record.  This has led to the recoupment of overpayments by Novitas Solutions, Inc totaling over $355.64. More importantly, when CMS and CERT extrapolate these errors to the universe, they will account for approximately $22.1 million in claims payment errors for the November 2012 report.

Medicare defines a Diagnostic Test as including: 

"All diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary."

And further defines Clinical Laboratory Services as:

"The biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition."

CMS also gives direction that Clinical Laboratory Services "must be ordered and used promptly by the physician who is treating the beneficiary."

CMS defines an order as:

" A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y)."

An order can be written in the beneficiary's record or can be a telephone order from the physician's office to the testing facility.  If a telephone order, both the treating physician and the testing facility must have documented in the beneficiary's record the telephone call and the extent of the diagnostic tests being ordered. 

EDI - rejection - provider specialty code, Expired tax id

 000 ERROR: Provider's specialty code

What this means: The rendering provider information is either incomplete or missing from the   EDI system, or it doesn't match what is being sent on the claim.  

Provider action: Check the rendering provider.  Is it present on the claim?  Is it a provider you have already added to   EDI?  

Rejection Removal: Rejections will not be removed by   EDI as they are valid. 

Re-filing: Once this is corrected, you would want to re-file any

*Expired Tax ID  Dr. XXXXXX

What this means: The tax ID and provider information that the payer has on file is not longer set up in the payer system. 

Provider action: Please contact provider relations at insurance to make sure your provider information is active in their system,

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

*Wrong Name .

What this means: The provider name being sent on the claim is coming over in first name last name format, ASHN wants it in last name, first name format. 

Provider action: Check the rendering provider.  Is it present on the claim?  How are you sending the name? 

Rejection due to NPI cross walk, Data element missing

Crosswalk did not give 1 to 1 match for NPI 

What this means: The payer does not recognize the provider matched to the NPI tax ID combination in thier system. 

Provider action: Check your NPI and tax ID numbers, are you sending the claim how you are credentialled with the payer, verify this provider is credentialled under the Billing NPI or individual provider NPI.  You may need to contact the payer to retrieve this information? 

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.

A data element with 'Must Use' status is missing. Element CR104 

What this means: Some claims submitted October 29, 2012 through November 6, 2012 erroneously rejected with the message, “A data element with 'Must Use' status is missing. Element CR104 (Ambulance Transport Reason Code) is m". 

Provider action: No provider action is required. 

Rejection Removal: Rejections will  be removed by   EDI as they are invalid.

Re-filing:   EDI will re-process the affected claims.

How to avoid or preventing duplicate denial OA 18

Exact duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)

(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)

Resources/tips for avoiding this denial

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.

• Click here to review article on new claim system edits regarding duplicate claims.

• Ensure necessary appropriate modifiers are appended to claim lines.

• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.

Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

How claim filing denial calculated from the DOS or receipt date

Determining End Date of Timely Filing Period—Receipt Date 

A submission, as defined above, is considered to be a filed claim for purposes of determining timely filing on the date that the submission is received by the appropriate Medicare claims processing contractor.  At this point, the submission receives a permanent receipt date that remains part of the claim record.  Once a submission (or claim) passes edits for completeness and validity described , it is accepted into the Medicare claims processing system. 

The receipt date has two functions. It is used for determining whether the claim was timely filed (see 70.4 below). The same date is also used as the receipt date for purposes of determining claims processing timeliness on the part of the intermediary. (See §80 for details on determining claims processing timeliness.)

Determination of Untimely Filing and Resulting Actions

Medicare denies a claim for untimely filing if the receipt date applied to the claim exceeds 12 months or 1 calendar year from the date the services were furnished (i.e., generally, the “From” date, with the exception of the “Through” date for institutional claims that have span dates of services, as specified in §70.1). When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”.  As such, the determination that a claim was not filed timely is not subject to appeal. 

Medicare New Edit - new patient CPT billed two times within three years

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years

Note: This article was revised on June 4, 2013, to reflect the revised CR8165 issued on May 31. The article shows a revised list of new patient CPT codes and an added list of established patient CPT codes on page 2. Also, the CR release date, transmittal number, and the Web address for accessing CR8165 have been revised. All other information remains the same.

Provider Types Affected 

This MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (carriers and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action Needed 

This article is based on Change Request (CR) 8165 which informs Medicare contractors about changes to Medicare's Common Working File (CWF) system that will detect erroneous billings when there are two new patient Current Procedure Terminology (CPT) codes being billed within a three year period of time by the same physician or physician group.

Make sure that your billing staffs are aware of these changes. See the Background and Additional Information Sections of this article for further details regarding these changes.

The Recovery Auditors, under contract with the Centers for Medicare & Medicaid Services (CMS), are responsible for identifying and correcting improper payments in the Medicare Fee-For-Service payment process. The Recovery Auditors have identified claims with "New Patient" Evaluation and Management (E&M) services to have improper payments, because the new patient services have been billed two or more times within a 3-year period by the same physician or physician group. The "Medicare Claims Processing Manual," Chapter 12, Section 30.6.7 provides that “Medicare interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E&M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit.”

Medicare new patient claim edit and how to appeal on denial ?

Medicare E/M claims for new patients

As previously announced with MM8165, Medicare implemented a common working file system edit to  identify claims where more than one new patient visit was billed for the same patient within three years.  Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period.

In addition to this new edit, the common working file has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period.  This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit.  As a result of these new edits, you may begin to see services deny on the original claim submission or you may receive an overpayment request.

If you receive this denial on a new patient visit (not an overpayment request) and you determine that the procedure code should have been filed as an established visit, you can simply call the interactive voice response (IVR) system and request a reopening. Additional IVR reopening information can be found by clicking here. If you do not want to use the IVR for this, you have the option of submitting a new claim or writing in for a reopening.

Note:  Submitting a new claim for the revised established E/M visit will not result in a duplicate denial since the original visit code was not paid.CMS has mandated that contractors request overpayments on any claims that were previously paid when either:

An established patient visit was billed prior to an iitial visit within a three year period by the same rendering provider; or

More than one new patient visit was billed within a three-year period by the same provider or different providers in the same group with the same specialty.

Medicare HMO denied the claim as covered by hospice

Claims From Medicare Advantage Organizations

Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found that Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.

A - Covered Services

While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS. These claims are subject to the usual Medicare rules of payment, but only for the following services:

1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;

2. Services of the enrollee’s attending physician if the physician is not employed by or under contract to the enrollee’s hospice;

MISSING EFT ENHANCEMENT - Medicaid denial

DESCRIPTION OF THE ISSUE

The Medicaid claims statuses states; the pay to provider is not eligible for direct payment.

CONCEPT

Any carrier should possess EFT enhancement during enrollment process inorder to obtain any claim status during verification.

SOLUTION

Upon verification with the Provider enrollment @ Medicare, the EFT Authorization form was submitted. Later the Billing Indicator was changed to "Yes" and the necessary billing information was updated. Finally all the claims were processed and paid

RAIL ROAD MEDICARE REQUESTS FOR PROVIDER’S PTAN#

DESCRIPTION OF THE ISSUE

PTAN# was not issued for Dr. .  Hence all the RR MCR claims were in pending for long duration.

CONCEPT

RRMCR requests for appropriate PTAN# for processing its claims.

SOLUTION

After regular follow-ups with the Insurance on request to issue PTAN#, we received the same after 60 business days and all the outstanding claims were processed and paid.

INCORRECT TIN# FILED FOR A CAPITATED CARRIER

DESCRIPTION OF THE ISSUE

The claims of Wellcare were initially denied for “No Authorization on file”. {submitted with the Tax-Id# 123456789}.

CONCEPT

If a provider is capitated under a plan, we need to verify on all the information of the provider with the concerned Insurance records to avoid denials of missing/incorrect provider’s information.

SOLUTION

Upon verification with Wellcare we found Dr.  had separate Tax-Id# 987654321 and was capitated with this plan. Hence all the claims were refiled and processed under capitation

PROVIDER INELIGIBLE TO FILE CPT 81001 - Denial reason

DESCRIPTION OF THE ISSUE

We received denials for the CPT 81001 as “Provider is not certified eligible to perform this procedure” - CPT 81001 (Urinalysis with microscope) 

CONCEPT

Any provider should be aware of his eligibility of the services to be performed for appropriate reimbursements. 

SOLUTION

Per Coding Dept’s advice we changed CPT from 81001 to 81002 (Urinalysis without microscopy) and refiled all the denied claims for reprocessing.  The refiled claims were paid successfully. 

REJECTION OF WHOLE CLAIMS WITH J CODES FOR NDC# UPDATE cpt code - j7613, j7609

DESCRIPTION OF THE ISSUE

Claims filed without or incorrect NDC#s, MCD HMO carriers (Staywell/Health Ease) rejected entire claim for NDC# updates, instead of processing denial only for J Codes.

CONCEPT

All injection drug codes should be billed along with NDC# updates for the claims to be reimbursed.

SOLUTION

Carriers’ database setup has been modified to reject the entire claim when filed with J Code without/Incorrect NDC#s, instead of processing denial only for the J Code.  So we segregated J code as a separate claim.  This enhanced payment for rest of the CPTs and the J code alone was denied for need of NDC#.

IS cpt code 81001 valid - replacement code G0431

CPT G0431 replaces CPT 80101 for Drug Screen Testing 

 

Change Request 6852 addresses CPT G0431 "Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class" as a direct replacement of CPT 80101.  

The following conditions become effective on April 1, 2010: 

Providers must use CPT G0431 when billing for these services CPT 80101 will no longer be covered by Medicare for dates of service January 1, 2010 and after

For complete information, refer to the CMS Medicare Leaning Network (MLN) article MM6852 "Clinical Laboratory Fee Schedule (CLFS) - Special Instructions for Specific Test Codes (CPT Code 80100, CPT Code 80101, CPT Code 80101QW, G0430, G0430QW, and G0431QW)."

HOSPICE CLAIMS SUBMITTED DIRECTLY TO MCR INCORRECTLY

DESCRIPTION OF THE ISSUE

Previously we had billed Hospice covered patient claims to Medicare with GW modifier to get quicker payments. Balance of 20% coinsurance was billed towards patients. Client raised an issue to file the claims to the concerned Hospice care itself instead of billing Medicare.

CONCEPT

Whenever we find patients with Hospice coverage for a particular service date, we must check with Hospice whether the patient was in Hospice for the specific DOS, if yes we must bill that concerned Hospice care and not Medicare, if not we could bill Medicare with GW modifier (which indicates the claim not related to Hospice).

SECONDARY MEDICAID CLAIMS DENIED AS “MEDICARE COVERAGE IS PRESENT”

DESCRIPTION OF THE ISSUE

Secondary Medicaid denied claims as Medicare coverage is present/ Crossover data missing at detail level. As per our conversation with Medicaid they do not cover the balance left from Primary Medicare HMOs.

CONCEPT

If patient have Medicare HMO as primary Insurance and Medicaid as secondary, such scenario claims have been denied like this.

SOLUTION

Before we bill claims to Secondary Medicaid we need to check the paid amount of the primary carrier with Medicaid fee schedule and if the amount greater than the Medicaid allowable we could waive the balance off

PSYCHIATRIC REDUCTION ON MEDICARE CLAIMS - PAYMENT REDUCED

DESCRIPTION OF THE ISSUE

Whenever we use Psychiatric related diagnosis as primary one on a claim, this will cause a payment reduction from Medicare. The reduction has covered by some of the commercial secondary Insurances and if the patient does not have such, we could not bill the balance amount fully to the patient responsibility, we can only bill the 20% of the Medicare balance to patient not the reduced amount.

CONCEPT

If a patient treated for an Office/ Hospital visit based on the Psychiatric problem and if the patient needs specialty treatment, this would cause reduction on payment.

SOLUTION

Once we receive a claim with primary diagnosis related to Psychiatric (ICD Starts from the numeric 3) we need to check with Client Office whether there is any alternative primary Diagnosis. If reduction done by Medicare then we should correct primary ICD through Medicare IVR Telephone Clerical Reopening option

W9 FORM IS NOT REACHING THE CARRIER

DESCRIPTION OF THE ISSUE

All the claims under Orlando Health care are awaiting for W9 form from the provider.

CONCEPT

Carriers request on any information should be submitted for the claims to be reimbursed.

REASON

Upon several submission of W9 form of the provider either through fax and despatch haven’t reached the carrier.  We are in process of getting approval of receiving W9 form from the Carrier.