Coding Denials
What steps do you take to resolve denial B9-Patient is enrolled in Hospice?
Add the GV modifier to the CPT in Expanse. If the denial was from MCR you correct on the portal. If it was for a replacement plan you locate the patient MCR policy # and update the account to MCR primary and submit the claim.
What is the resubmission code needed when requesting a void of payment/payments?
What tab do you click on to take an adjustment?
Quick Txns
When there are multiple flags on an account in mPower do you need to leave a note in each action to clear the flags?
No, if you have explained in the first note everything you did in the account you can just put a period in all the other note boxes (where you can free type).
Name the behavioral health crossover payer for UHC.
UBH/Optum
Explain denial reason B16-New qualifications were not met means.
The payer says the patient has been seen by that provider within the last 3 years.
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Where do you add or remove a modifier?
Process Txns on the right side and Txn Detail in the bottom.
When sending a task to Coding, what category should you select before on the right side of the New Task screen?
Coding. Also make sure to select None under the TXN Num column in the top box.
Name the current King/Queen of Great Britain.
King Charles
MCD denies the claim with a CARC 184-'The prescribing/ordering provider is not eligible to prescribe/order the service billed'. Where do you go to correct and what do you remove?
MH portal and you remove the name next to 'Ordering Provider Name'.
Explain denial reason CARC 151-Payment adjusted because the payer deems the info submitted does not support this many/frequency of services.
The payer is denying the claim because this service was billed too soon within the alotted time frame based on the frequency allowed for the procedure
Where do you go to reverse a CPT code in Expanse?
Process Txns making sure you are under the Charges tab at the top.
What modifiers would you need to add to a claim if you switch the insurance from HNE Be Healthy to MBHP?
For MDs or DOs: U6
For RNs or NP: SA
Do we bill claims to MCD Health Safety Net or MCD Limited and why?
Both of these policies only cover emergencies or hospital charges only. Physician charges are not covered.
MCD denies the claim with a CARC 183-'The referring provider is not eligible to refer the service billed.' Where do you go to correct and what do you remove?
MH portal and you remove the name next to 'Referring Provider Name'.
Where in Expanse can you change the patient's name to match their insurance ID card/policy?
Under the insurance tab you edit the insurance and go to the Subscriber tab and enter the name as it appears on the ID card.
How do you locate proof of timely filing?
In nThrive: Use the search box and enter the MP or MPA number.
What information do you need to put in a request to Coding for review?
CPT code in question
The reason for request. This does not mean the denial reason from the EOB. Reword the denial to summarize (Claim denied for missing/inconsistent modifier for CPT ##### on DOS 1/25/24. Is there a different modifier that can be used instead).
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MCDPCC denied the secondary claim with a CARC 4-'The Procedure Code is Inconsistent with the Modifier Used or a Required Modifier is Missing'. The provider billing this claim is a mid-level provider, how do you work this denial?
Since this was billed by the mid-level provider and no payment was made by MCD, you would reverse the charge to $.00 in Expanse. You would not need to resend the claim to MCD because we should not be billing for a mid-level provider.
Who is considered a Mid-level provider?
Nurse Practitioner-NP
Registered Nurse-RN
Physician Assistant-PA/Certified Physician Assistant-PA-C
Certified Nurse Midwife-CNM
You need medical records for a Cardiologist and you have looked in the EMR under 'All Visits' and you cannot find it there. Where else might you find it in the EMR?
Scanned Report-If it is lit up that means there is something scanned in there.
Why would you need to change a CPT code, and do you need permission to change CPT code?
An Office Visit was billed as a new patient, but they have seen this specialty with the last 3 years.
Yes, unless it is on the Denial Processing Spreadsheet.
You have a claim that MCR denies CARC 109-Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor. You check eligibility and the patient has a MCR replacement. What do you have to do so you can add the MCR replacement?
Deactivate MCR under 'Order be Effective Date' in the Insurance tab. The system will not allow you to add a MCR replacement plan when MCR is active.