Ch 13: Commercial Insurance Carriers Flashcards
Which modifier is used to indicate that an E/M service is unrelated to the global service?
24: Unrelated E/M by the same physician or other QHP during the Postop Period
What is a rejected claim?
a claim that does not contain the necessary information for adjudication
rejected by warehouse
What denial occurs when the claim is a liability case and was submitted to the health insurance?
Claim covered by other insurer
Significant, separately identifiable E/M by the same physician or other QHP on the same day of the procedure or other service is which modifier?
25
Which denial is one of the leading reasons a claim is denied and can be prevented by accurate intake information being collected every time?
Incorrect patient information
What’s the different between a Rejected Claim and a Denied Claim?
Rejected: a claim not containing the necessary information for adjudication (warehouse)
Denied: passed through the payers initial processing but was determined not to be a covered service or procedure (insurance)
Which Modifiers can be used to bypass bundling edits for services during global period that are unrelated?
Mod 24, 25, 58, 59, 78, 79
Patient Protection & Affordable Care Act (ACA)
provides provisions for appeals process by health insurer. Process must include:
- appeal process
- notice to enrollees
- allows enrollee to review and present evidence
- external review process
If a provider wishes to submit for a single-level provider payment review from Cigna, what is the timeframe for this type of dispute?
180 days - single-level review must be initiated within 180 days from the date of initial payment or denial decision from Cigna
What information/documents are required for submitting an appeal to Cigna?
Original EOB, completed appeal form, and documentation that justifies why the decision should be reversed.
If a denial is received on UHC claim, a reconsideration
must be submitted within what timeframe of the date of the EOB/RA?
within 12months of the date of EOB/RA
For Aetna, how long does a provider have to file a reconsideration? What’s Aetna’s turn around time?
180 cal days of the initial claim decision.
Turn around = 3-5 business days from received.
30 business days of received if review by speciality unit.
For Aetna, how long does a provider have to file an appeal? What’s Aetna’s turn around time?
within 60 cal days.
Turn around = 60 business days or received.
if additional info is needed, within 60 cal days from received.
Services that are appropriate to evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care are considered what?
Medical necessity
On 05/02/20, a claim for an excision of a chest wall tumor, including ribs was reported with CPT Code 19260 and ICD-10-CM code D49.89 for DOS 05/01/2020. Why would the claim be denied?
CPT 19260 was deleted in 2020
it would be denied for invalid CPT for DOS
What is one way to assist in lowering denials for non-covered services?
A biller cannot be expected to know every exclusion that each plan carries but should be aware of the most common exclusions in the major plans that their office contracts with.
If a claim is denied, investigated, and found to be denied in error, what should a biller do?
Appeal the claim.
Which regulations require a health insurer offering group or individual coverage to implement an effective appeal process for appeals of coverage determinations and claims?
Patient Protection and Affordable Care Act - it provides provisions for the appeals process. (Guidelines/policy/steps to an appeal)
An initial denial is received from Aetna. The denial is investigated and the office considers that the payment was not according to their contract. According to Aetna’s policy, what must the biller do?
Submit a reconsideration - AKA a formal review of a claim’s reimbursements.
According to Cigna, what is the best way to resolve claim processing errors?
Contacting the claim service center.
- contractual disputes for denials and payment disputes are resolved through single level appeals
What can be done in the practice to ensure that liability denials will not be received?
* liability = who is responsible?*
Liability issues can be avoided with a thorough intake of the patient at the time of service.
Dont assume the commercial insurance should be billed or that the patient was injured at work.
What rejections/denials are the easiest to prevent with good front office policy?
- incorrect patient information
- eligibility expiration
- liability denials
What does it mean if a claim is denied for Prior Authorization/ referral not received?
Some commercial plans require an authorization to be obtained prior to services being rendered for:
nonemergent procedures
nonemergent admissions
radiology services
* HMOs require referrals
*** Authorization number is entered in item 23 on the CMS-1500 form
What should be done when a denial is received that states there is a global surgery package bundling issue?
check RBRVS, CPT, and payer policies
