Claims and Coding
This field on the CMS-1500 must match the rendering provider's NPI in the payer system.
What is box 24J?
A CO16 denial often means this.
What is missing or invalid information?
This modifier is often required for commercial payers to recognize telehealth.
What is 95?
Before rendering services, this must always be confirmed.
What is patient eligibility?
This is the mental health payer for many Blue Shield HMO plans in California.
What is Magellan?
When submitting a corrected claim, this field must be populated.
What is the Claim Frequency Code "7"?
When a claim denies for coordination of benefits, you must first do this.
What is verify which plan is primary and update COB with the payer?
These are the two POS codes used most for telehealth billing.
What are POS 02 and POS 10?
If an authorization number is missing, the claim might deny for this code.
What is CO197?
UBH (Optum) Medicare Advantage plans often carve out mental health benefits to these groups.
What are IPA or delegated medical groups?
These two things must be updated when a patient gets a new ID but keeps the same payer.
What are the member ID and eligibility details?
You receive a denial for "benefit not covered under patient's plan" The next step is:
What is check the benefit details and notify the Front Office immediately, if applicable.
This is the difference between GT and 95 modifiers.
What is GT is older but some payers still require it and 95 is more widely accepted now?
This system or tool is often used to verify most insurance plans.
What is Availity?
This behavioral health claim rule applies uniquely to Kaiser patients in Southern California?
What is services must be authorized and billed under the delegated medical group, not Kaiser directly?
The billing code 90847 is used for this type of session.
What is family therapy with the patient present?
A claim was denied because a rendering provider is out-of-network. The next step is...
What is verify the Credentialing Grid and identify the root cause of why the provider is showing out-of-network.
This requires modifier 93.
What is audio-only?
A retro authorization is:
What is an authorization requested after services are rendered?
When Aetna contracts with a delegated IPA, this is the best way to verify where to submit claims.
What is check the back of the insurance card or contact Aetna Provider Services.
These three elements are needed to calculate time-based CPT codes.
What are start time, end time, and total face-to-face time?
A claim denies for "duplicate claim." Name two causes that trigger this.
What are resubmitting without correction/frequency code, or submitting a claim before the original has been processed?
This term refers to real-time, interactive audio and video communication.
What is synchronous communication?
If eligibility shows active coverage but claims are denying for "no coverage on file," this is likely the issue.
What is incorrect subscriber ID or outdated policy details?
A claim submitted to the wrong entity under a delegated plan may be denied for "services not covered." Do this next.
What is verify whether the plan is delegated and confirm the correct billing entity (IPA, TPA, or payer)?