Author Topic: denial reasons  (Read 4835 times)

MDO VN

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denial reasons
« on: November 20, 2008, 01:13:29 AM »
Hi Michele,

Happy Holiday!

I would like to ask for an unclear denied reason:

I billed 99215/87880 with DX 250.00, 462, 464.00, 466.0 for a patient and MED denied
- 99215 with code B15:This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received /adjudicated.
- 87880 with code B7: This provider was not certified/eligible to be paid for this. procedure/service on this date of service

Could you please share your thoughts?
Thank you,
Kristy

Michele

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Re: denial reasons
« Reply #1 on: November 20, 2008, 06:33:54 AM »
Kristy,
    Based on the denial for the 87880 it sounds like you have an issue with the provider's participation with Medicare.  I'm assuming both services were on the same date of service.  The first denial doesn't make much sense, but the second denial is indicating that the provider was not credentialed with Medicare on the date of service under the NPI number that you are billing with.  Did the provider recently change his NPI from an individual to a group?  Another common cause is if the provider is billing under a tax ID & group NPI but they originally enrolled in Medicare under their ss#.  This will cause claims to be denied as well.  I would call Medicare and ask why he wasn't eligible on that date of service.  Try verifying the tax ID & NPI, because the Medicare reps are not always helpful enough to dig in a little to find the problem.  But if you ask to verify they will have to check into it.

Good luck
Michele
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MDO VN

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Re: denial reasons
« Reply #2 on: November 25, 2008, 02:07:54 AM »
Thank you Michelle for your suggestions, I will call Palmetto and verify with Rep.
Wish you all the bests,
Kristy

MDO VN

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Re: denial reasons
« Reply #3 on: December 08, 2008, 10:21:24 PM »
Hi Michelle,

Please share your thoughts on this code C0-24 of MED: Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan.

Thank you,
Kristy

Michele

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Re: denial reasons
« Reply #4 on: December 09, 2008, 05:47:04 AM »
That means that the patient is enrolled in one of the Medicare HMO's (replacement Medicare product) and it takes the place of Medicare.  You need to find out which plan it is and bill them directly.  For example, they may have American Progressive Today's Options, or UHC Secure Horizons.  They are Medicare replacement plans with independent insurance carriers.  You need to bill them INSTEAD of billing Medicare.  They usually have assigned their own ID#'s to the patient so you need to find out which plan they have, and get their ID#.

If you don't have any way to contact the patient easily by phone, or them coming in to the office, we send a bill explaining that they have enrolled in a Medicare HMO and we need to know who the carrier is, and what their ID# is. 

Michele
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MDO VN

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Re: denial reasons
« Reply #5 on: December 10, 2008, 07:37:49 AM »
I got it now :) Thank you Michelle. Hope you are having a great week!

marypete

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Re: denial reasons
« Reply #6 on: December 10, 2008, 10:09:58 PM »
It needs to be billed as 87880 qw as it is a CLIA waived test. Otherwise, it will get denied because the provider is not certified to do this test under his CLIA certification.

Michele

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Re: denial reasons
« Reply #7 on: December 11, 2008, 06:27:36 AM »
Thanks marypete.  I missed that one too!

Michele
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MDO VN

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Re: denial reasons
« Reply #8 on: December 19, 2008, 02:55:40 AM »
Dear Michelle,

Could you explain to me more details about "Glogal period" or suggest me where I can read about it?

Thank you,
Kristy

Michele

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Re: denial reasons
« Reply #9 on: December 19, 2008, 01:41:22 PM »
I'm assuming you meant "Global Period" :) 

The global period is:  A period of time immediately prior to or after a surgical procedure in which all routine follow-up care is included in the original charge amount. ...

Hope that helps.

Michele
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MDO VN

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Re: denial reasons
« Reply #10 on: December 22, 2008, 09:20:59 PM »
i got it now, thanks so much.
Merry Christmas!
Kristy

Michele

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Re: denial reasons
« Reply #11 on: December 23, 2008, 01:14:09 PM »
No problem.  Same to you! :)

Michele
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