Claim Denials-
What to do?
What to do?
Claim is denied due to an invalid operating provider
1. Check eMed to verify whether the provider is enrolled in Medicaid.
2.For inpatient accounts, email Stacie C. for a coding review and forward the email to Regina to submit a corrected claim.
A claim is being denied as non-covered due to lack of medical necessity.
Send for an appeal
38008520
NO/INCORRECT AUTH
JAPP
APPEAL ISSUE
The Titanic had enough lifeboats for everyone on board.
False, The Titanic carried lifeboats with space for about 1,178 people, but more than 2,200 people were on board.
Ins denied claim for missing accident details.
1. Verify in PowerChart whether the visit was accident-related.
2. Contact insurance to verify the denial and confirm if accident details were submitted.
3. If submitted, request claim reprocessing. If not, contact the patient and follow the non-compliance process.
insurance is denying claim for missing medical records, per prior notes verisma has already sent them at an earlier date. Multiple attempts were made to send claim back, but the ins are not moving on denial.
Send to the JOC
38000261
COVERAGE TERMINATED
JNBN
OBSETETRICS/NEWBORNS ISSUE
Napoleon Bonaparte was unusually short for his time
False, Napoleon was about 5 feet 6–7 inches tall, which was average or slightly above average for a French man in the late 1700s.
What are the proper steps to take when a PST/PAT claim is denied?
1. Review the claim to confirm whether occurrence codes 40 and 41 are present.
2. Verify whether the surgery is inclusive of the PST service.
3. If the surgery is inclusive, process a write-off. If it is not inclusive, automatically JOC the claim.
Bonus: Which JOC activity should be used?
Ins denied claim as experimental.
Send to rtda for an appeal
38008629
BABY NOT ENROLLED
JMOD
MODIFIER ISSUE
Cleopatra lived closer in time to the Moon landing than to the construction of the Great Pyramid.
True, The Great Pyramid was completed around 2560 BC, Cleopatra lived around 30 BC, and the Moon landing occurred in 1969. Cleopatra is closer in time to the Moon landing.
Claim has been processed by the insurance but total charges have been made pt responsibility. We are OON with the ins and the policy is a limited benefit plan.
verify if patient's plan has OON benefits, Get a copy of EOB, Bill' em
JOC
38008645
INCORRECT SUBSCRIBER
JPHA
PHARMACY ISSUE
During the eruption of Mt Vesuvius (Pompeii) to avoid the falling rock they wore pillows on their heads
True, many residents of Pompeii tied pillows and cushions to their heads to protect themselves from the raining rocks and pumice
Claim has denied for timely filing, on a no fault/ worker's comp account.
Check the primary ins EOB to see their date of denial, if within time frame send timely filing appeal or if past timely claim submission write it off as untimely
Claim denied for no authorization. after investigating an auth was found approved with a different CPT code, but per the ins policy the CPT approved is considered a grouper code allowing for overall coverage.
Send back for reprocessing
38008538
JRTL
CONTRACT RATE LOAD ISSUE
Was there a flood of molasses in Boston
True, The Great Molasses Flood, also known as the Boston Molasses Disaster, was a disaster that occurred on Wednesday, January 15, 1919, in the North End neighborhood of Boston, Massachusetts