Author Topic: UHC all denial reason and solutions  (Read 10037 times)

Sivakumar

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UHC all denial reason and solutions
« on: January 23, 2013, 12:30:00 PM »
i just handling NY state practice old.AR accounts. most of the UHC accounts get denied for different reason..
can anyone send me the denials list & resolution details. or just give me a website like to download..

thanks..

Christy

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Re: UHC all denial reason and solutions
« Reply #1 on: January 23, 2013, 12:33:58 PM »
the denial reason should be right on the eob....

RichardP

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Re: UHC all denial reason and solutions
« Reply #2 on: January 23, 2013, 02:24:45 PM »
Such a list for UHC probably does not exist officially.  However, the denial codes for regular insurance carriers follow somewhat the denial codes for Medicare and Medicaid.  Here are a few links to get you started with your research:

http://www.webanswers.com/health/how-can-i-find-a-list-of-medicare-denial-codes-562caa?FS999_rli=1

http://medicalbillingguideline.org/medicare-denial-code-first-list/

http://dese.mo.gov/divspeced/Finance/PDF/MedicaidClaimDenialCodes.pdf

http://www.ncdhhs.gov/dma/hipaa/eobcrosswalk.pdf
« Last Edit: January 23, 2013, 02:26:44 PM by RichardP »

Sivakumar

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Re: UHC all denial reason and solutions
« Reply #3 on: January 23, 2013, 08:42:16 PM »
Thanks for the reply..

i hope those websites will help me to clear my doubts..

PMRNC

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Re: UHC all denial reason and solutions
« Reply #4 on: January 24, 2013, 08:53:34 AM »
Quote
i hope those websites will help me to clear my doubts..

Your EOB's should be your first resource, as they will indicate the denial code and explanation of denial.
Linda Walker
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www.billerswebsite.com

Sivakumar

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Re: UHC all denial reason and solutions
« Reply #5 on: January 24, 2013, 12:11:54 PM »
we can see remit codes and reasons in the eob.. but i don't know what is the appropriate action for the denial (ex: provider not eligible to perform this service ) this is one of the denial which i receiving from UHC often. even the provider is participated with the payer.

i have no idea why UHC using this denial..

RichardP

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Re: UHC all denial reason and solutions
« Reply #6 on: January 24, 2013, 02:29:34 PM »
(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.

PMRNC

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Re: UHC all denial reason and solutions
« Reply #7 on: January 24, 2013, 02:33:38 PM »
Quote
we can see remit codes and reasons in the eob.. but i don't know what is the appropriate action for the denial (ex: provider not eligible to perform this service ) this is one of the denial which i receiving from UHC often. even the provider is participated with the payer.

Richard gave you good overview of how denials work. I have to ask though.. Have you CALLED UHC?  THAT denial ( provider not eligible to perform this service) tells me that the provider is proving a service outside the scope of their license to which this carrier has set. It could be state law. Without knowing procedure, type of provider and their licensing it's too hard to guess.   MY first thought would be to contact the carrier directly and just flat out ask them if it wasn't obvious to me.   Are you by any chance "offshore"? That might contribute to the lack of education regarding state/federal licensing requirements in the US.  Sorry, I had to ask the obvious.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

RichardP

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Re: UHC all denial reason and solutions
« Reply #8 on: January 24, 2013, 02:38:13 PM »
Hmmmm.  I saw your post right after I posted mine, even tho the time says we posted 3 minutes apart.  So I am assuming that you were referring to my first post rather than my second??  (I don't see how you could possibly have read my second post, typed your response, and posted it that quickly.)  Interesting that we said - independently I think - roughly the same thing only minutes apart.  There must be some truth to what we say. 
« Last Edit: January 24, 2013, 02:44:17 PM by RichardP »

Sivakumar

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Re: UHC all denial reason and solutions
« Reply #9 on: January 24, 2013, 08:32:06 PM »
(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.

now i just got an idea how to find out the solution.. I'll find out the solution and let u know my findings...

Sivakumar

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Re: UHC all denial reason and solutions
« Reply #10 on: January 24, 2013, 08:38:30 PM »
Quote
we can see remit codes and reasons in the eob.. but i don't know what is the appropriate action for the denial (ex: provider not eligible to perform this service ) this is one of the denial which i receiving from UHC often. even the provider is participated with the payer.

Richard gave you good overview of how denials work. I have to ask though.. Have you CALLED UHC?  THAT denial ( provider not eligible to perform this service) tells me that the provider is proving a service outside the scope of their license to which this carrier has set. It could be state law. Without knowing procedure, type of provider and their licensing it's too hard to guess.   MY first thought would be to contact the carrier directly and just flat out ask them if it wasn't obvious to me.   Are you by any chance "offshore"? That might contribute to the lack of education regarding state/federal licensing requirements in the US.  Sorry, I had to ask the obvious.

yes I am "offshore".. that is the reason i am not much familiar with us law and regulations.. but i am completed CCAT certifications successfully..

I did not check with UHC rep.. I'll talk them and let u know the reason for the denial..

Really thanks for your assistance..

RichardP

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Re: UHC all denial reason and solutions
« Reply #11 on: January 24, 2013, 08:51:59 PM »
now i just got an idea how to find out the solution..

Lightbulbs.  That is what some of us are trying to do here - turn on lightbulbs.

PMRNC

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Re: UHC all denial reason and solutions
« Reply #12 on: January 24, 2013, 09:31:37 PM »
Over and out on this.. All yours  ;)
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com