Denials

Question 1

Claim Denied for Coverage Terminated - PR26/27

Answer 1

1) Denial Date
2) Start & End Dates of the Policy
3) If:
a) Active: Reprocess > TAT, Cl#, Ref#
(Follow-up after TAT Period)
b) Inactive:
Is there any other Active Policy?
i) Yes > Ins. Details, Cl#, Ref#
(Task to EVBV Department)
ii) No > Cl#, Ref# (Bill to Patient)

Question 2

Claim Denied for Untimely Filing Limit - CO29

Answer 2

1) Denial Date
2) Received Date
3) TFL as per Insurance Guidelines
4) If:
a) Within TFL:
Reprocess > TAT, Cl#, Ref#
(Follow-up after TAT)

b) Crossed TFL: Check POTFL!
i) Within as per POTFL:
Appeal with POTFL?
> AFL, Appeal Address, Fax#, Cl#,
Ref# (Submit Appeal with POTFL)
ii) Crossed as per POTFL:
> Cl#, Ref#
(Write-off/ Adjust Claim)

Question 3

Claim Denied for Capitation Period - CO24

Answer 3

1) Denial Date
2) Start & End Dates of the Capitation
Period
3) If:
a) Within: Cl#, Ref#
(Task to Payment Posting Dep.)
b) Crossed: Reprocess > TAT, Cl#, Ref#
(Follow-up after TAT period)

Question 4

Claim Denied for Non-Covered Services - CO96

Answer 4

1) Denial Date
2) Non-Covered as per Patient’s Plan
or Provider’s Contact?
A) Patient’s Plan: Which services are
Non-Covered?
a) Truly Covered:
Reprocess > TAT, Cl#, Ref#
(Follow-up after TAT Period)
b) Truly Non-Covered:
Any other Active Plan?
i) Yes: Ins. Details, Cl#, Ref#
(Task to EVBV Department)
ii) No: Cl#, Ref#
(Bill to Patient)

B) Provider’s Contact: Which services
are Non-Covered?
a) Truly Covered:
Reprocess > Cl#, Ref#, TAT
(Follow-up after TAT Period)
b) Truly Non-Covered:
> Cl#, Ref#
(Task to Client Assistance)

Question 5

Claim Denied for Inclusive - CO97

Answer 5

1) Denial Date
2) What is Primary Procedure Code/
Which Procedure Code is it Inclusive
with?
Check in NCCI Portal
3) If
a) Truly Inclusive:
> CCFL, Mailing Address,
Fax#, Cl#, Ref#
(Task to Coding Department)
b) Truly Non-Inclusive:
Reprocess > TAT, Cl#, Ref#
(Follow-up after TAT Period)

Question 6

Claim Denied for Medically Not Necessary (Commercial) - CO50

Answer 6

1) Denial Date
2) What sort of Documents do you
need to prove Medical Necessity?:
> CCFL, Mailing Address, Fax#, Cl#,
Ref#
(Need to send MR with Claim)

Question 7

CO50 (Medicare)

Answer 7

1) Denial Date
2) As per LCD/NCD guidelines what is
Article Number?
3) If:
a) Valid PX/DX Code:
> Transfer to Reopening line?
> Reprocess >