(ex: provider not eligible to perform this service )
Codes are attached to procedures. Procedures are attached to specialties. Specialties are generally restricted to a finite population of procedures that are relevant to that specialty. Editing rules in the insurance carriers' claim scrubbing software know this and edit incoming claims for it. Therefore, if you are submitting claims for an OB/Gyn guy, and you have codes dealing with heart surgery on those claims, your claims will get rejected with a message similar to the example you provided. OB/Gyn's are not supposed to be doing heart surgery, so the insurance carrier was correct to reject the request for payment for procedures dealing with heart surgery. Part of learning to be a good biller is learning what procedures (and associated codes) are legitimate for your doctor to ask to be paid for, according to his specialty. And then find a way to get him paid for the work he does, using modifers when and where necessary. This is the part that you have to learn from experience.
i have no idea why UHC using this denial..
This is where good billers earn their money. They have taken notes during experiences such as this and have learned over time what code combinations will get their doctor(s) paid and what won't. The insurance companies are not going to tell you this, except for the random person who might explain things to you. So take notes, and learn, when you encounter a problem and then learn its solution.
I've seen too many billers who didn't know why a charge was denied, the doctor didn't know how to interpret the carriers denial message, and so the monies were just written off. What incentive does an hourly worker (or offshore worker) have to expend energy on these types of tasks? Good billers know what codes to use to get their doctor paid, and so rarely get denials. But when they do get denials, they generally can tell what they did wrong, correct it, resubmit the bill, and get the doctor paid.
