Chapter 13 Commercial Insurance Carriers Flashcards
In this chapter, commercial insurance carriers such as Aetna, UnitedHealthcare, and Cigna will be reviewed.
Understanding common denials from insurance companies
Explain the appeals process for Aetna, UnitedHealthcare, and Cigna
Common Denials/Rejections
*Implement front office policies and procedures to reduce front end errors that cause denials and rejections
*Understand when corrected claims and appeals are warranted
*Submit effective appeals
A rejected claim is a claim not containing the necessary information for adjudication.
A denied claim differs from a rejected claim.
A denied claim is one that passed through the payer’s initial claim processing but was determined not to be a covered service or procedure based on the payer’s coverage criteria.
Rejected Claim
you can fix it
Denied Claim
you can appeal it
Incorrect Patient Information
*misspelling
*incorrect DOB
*invalid sub #
Eligibility Expired
Another common denial occurs when the patient’s coverage was not in effect on the date of service submitted for reimbursement.
Insurance benefits should be verified before services are rendered to avoid this type of denial.
Eligibility verification identifies if a patient has other insurance or relies on self-pay. T
Prior Authorization/Referral Not Received
A claim will also be denied if prior authorization or precertification data is missing on the claim.
This type of denial may frequently occur with HMO patients.
Enrolled members may need services that require an authorization and referral from the member’s primary care provider (PCP)
Claim Not Covered by Insurer
Non-covered services provided to a patient will result in a payer denial. Exclusions or non-covered services refer to certain medical services excluded from the payer’s health insurance coverage under the patient’s plan.
Request for Medical Records Not Received
In some cases, a payer may request medical records to adjudicate a claim.
When records are requested by payers, the request should be completed quickly to keep the adjudication process moving forward and avoid a denial.
EXAMPLE
ABC Health Policy: Modifier 22 - Increased Procedural Services
To be considered for additional reimbursement when reporting modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual service or procedure is required
Coordination of Benefits Issues
Coordination of benefits (COB) is the process of determining which of two or more insurance policies will have the primary responsibility for paying a claim, and the amount that the other policies will contribute
EXAMPLE
UnitedHealthcare provides the following tips on submitting electronic COB claims:
COB electronic specifications
For secondary professional or institutional claims to be paid electronically, the COB information must be submitted in the applicable Loops and Segments. Loops include:
Claim Covered by Other Insurer
Similar to a coordination of benefits denial, this type of denial occurs when the claim is a liability case.
When a patient has had an auto or work-related accident, the commercial insurance plan will most likely deny coverage until the workers’ compensation, auto insurance, or other liability carrier has been billed.
This type of issue can be avoided with a thorough intake of the patient at the time of the visit
Missing or Invalid CPT®, HCPCS Level II, or Diagnosis Code
Current coding materials (books, software, encoders, etc.) should always be used to ensure that the most current codes are assigned on a claim. A biller needs to understand when other codes are required by a payer, such as HCPCS Level II by Medicare or other carriers and Category III codes versus unlisted or other CPT® codes.
A quality assessment of coding should be performed on a routine basis for all staff who assign codes.
Offer education on coding and billing so staff can keep up with the latest methodologies. If this type of denial is received, the medical record should be pulled and reviewed along with the charge entry to assess if the claim was coded and submitted correctly.
EXAMPLE
This claim has procedure code 99224 reported for a 2024 date of service. In the CPT® code book, 99224 is a deleted code for 2024. The coding department should determine if the medical records support a different code.
Timely Filing
Each payer has a timely filing limit that is published to make all providers aware of the time that is granted to submit a claim for payment. Some payers have a 90-day timely filing limit, some 180 days, some one year, and some are specified by individual contract
Duplicate Claim
If a claim has been adjudicated and a decision made, the claim is closed by the payer. If the claim is then resubmitted by the provider, a duplicate claim denial will be sent. Keeping track of outstanding claims and timely posting of payments should decrease this type of denial.
Medical Necessity Not Met for Service
*Medical necessity is defined by each payer, but when a medical necessity denial is received, it indicates the diagnosis code submitted with the procedure code does not meet coverage guidelines.
*Payers publish coverage determinations similar to Medicare’s Local Coverage Determinations, in which the payer indicates the circumstances for coverage for services and procedures.
*They indicate applicable procedure and diagnosis codes.
Termination of Coverage
If services were provided to a patient after their coverage was terminated for any reason
Bundled Service
If a service is billed that is bundled into another service, or falls under the global surgery package, it will be denied.
If the service is bundled, or is part of the global surgery package, it should be written off.
This denial is also received on valid claims in some instances when modifiers are not appended to the procedure to indicate that the global surgical package or bundling issue should not apply
For example, a patient is under a 10-day global period for an intermediate wound repair performed on his trunk, CPT® code 12034.
On the third day, the patient presents to the office with complaints of asthma exacerbation.
A claim for an E/M service is submitted but denied due to bundling issues. When the claim is reviewed, it is determined that modifier 24 can be applied to indicate the service was unrelated to the global service.
Modifier 24 was not appended to the E/M code on the original claim submission.
