Denials in Medical Biling and Actions-AR Denial Management 2021

11/12/21, 12:14 PM Denials in Medical biling and Actions-AR Denial Management 2021
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 BCBS ALPHA PREFIX LIST  BCBS ALPHA NUMERIC PREFIX LIST A2A TO Z9Z DENIAL REASON CODES AND SOLUTIONS 
BCBS PROVIDER PHONE NUMBER  MEDICAL BILLING DENIALS AND ACTIONS  PLACE OF SERVICE CODES 
ANTHEM BLUE CROSS BLUE SHIELD CLAIMS MAILING ADDRESS LISTS  UNITED HEALTHCARE CUSTOMER SERVICE PHONE NUMBERS 
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Medical Billing Denials and Actions Categories

 05/30/2018  admin  0 Comments
Denials in Medical Billing and Actions-AR Denial Management in Medical Billing: BCBS Directory (32)
Digital Marketing (2)
Whenever the claims get denied in medical billing, we need to take the following steps in order
to reimburse the claims. This are the most common medical billing denials we come across in Health Care (33)
medical billing: Medical Billing Denial Codes and Solutions
(13)
Additional information/Lack of information Play Schools in Bangalore (1)
Claim covered by another Payer, per co-ordination of benefits Prior Authorization (3)
Search Engine Optimizaton (8)
Claim has been forwarded to pricing center
Travel (1)
Claim was applied towards copay/coins
Valentine's Day Special (1)
Capitation Website Setup Tutorial (5)
Medical records
Coverage terminated
Duplicate Claim
Co-ordination of Benefits
Deductible
Provider out of network
Fax Back
Global
Hospice
inclusive/bundled/global
In-process
Maximum benefit has been reached
Maximum frequency has been reached
Medically not necessity
www.everestvision.com/medical-billing-denials-and-actions/ 1/17
Member Eligibility
Member not eligible at the time of service
Missing/Invalid CPT code

Missing/Invalid Diagnosis code
Missing/Invalid HCFA/CMS-1500
Missing/invalid Modifier
Missing/invalid Place Of Service
No claim on file Recent Posts
No authorization BCBS Provider Phone Number
Non covered charge BCBS ALPHA NUMERIC PREFIX LIST A2A to
Z9Z
Not covered by this payer or contractor
Health Insurance in the United States of
Offset Adjustment America
Claim Paid Primary Insurance and Secondary

Insurance
Past Appeal Limit Medicaid Provider Enrollment Phone
Number
Past timely filing
Patient can’t be identified
Patient enrolled in HMO
Patient enrolled in Hospice
Primary Paid more than sec allowable
Referral Authorization#
Need primary EOB
Required W9 form
Voice mail
Claim Paid
1 May I know the Claim received date
2 May I know the claim paid date
3 May I know the claim allowed amount
4 May I know the paid amount
5 Is there any patient responsibility(Co-pay, Deductible, Co-ins)
Check whether insurance Paid to Provider/Patient
If Provider If Patient
6 May I know the mode of payment whether it Go to Question # 8
is EFT or Cheque
Check EFT
May I know the the May I know the
check# EFT#
May I know whether it
is single check or bulk
check
If it is Bulk check : May I
know the bulk check
amount
May I know the check
issued date
May I know whether
the check is cashed or
not( if paid date is
more than 30 days
from the current calling
date)
May I know the check May I know
mailing address whether it is
single amount for
7 If check mailing
Bulk amount
address is wrong then
inform the rep that
check mailing address
is wrong and ask her to
stop the payment and
request them to resend
check with correct
mailing address
8 May I know any line items got denied( if the claim is more than one line item) if yes
9 May I know the denial reason else
10 Can I have the CPT code wise breakup details cal ref#
11 May I know the claim#
12 Can you please fax/send the Duplicate EOB (If paid date is more than 30 days but
still not resolved then we can request the duplicate EOB)
13 May I know the call ref#
Home
Claim is in process
2 May I know how many days it may take to process the claim
3 If the received Date is more than 30 days then need to ask below questions
4 May I know the reason for the delay
5 May I know the patient effective and termination date
6 When shall I call back to you
Home
Claim denied as Primary Paid Maximum / Primary

Paid more than secondary allowed
2 May I know the denied date
3 May I know your allowed amount for the
procedure code
4 Check primary insurance paid amount in
application, if it is less than the sec allowable then

clarify with ins rep
7 Could you please fax/mail the duplicate EOB
Home
Claim denied as Patient cannot be identified as our insured – Adjustment Code – PR 31 in

Medical Billing
1 Could you please check with Patient Name
2 Could you please check with Patient DOB
3 Could you please check with Policy#
4 Could you please check with Patient SSN
5 Could you please check with Patient telephone#
6 Could you please check with Patient address
7 Could you please check with Patient Subscriber( If patient is not self)
Home
Claim denied as Duplicate Claim/Service – Denial Code OA 18 / CO 18 in Medical Billing

3 May I know the original claim status
4 If original claim is denied go by the denied scenario
5 If it is paid go by the paid scenario and if it is in-process then go by the in-process
scenario
6 May the original and current claim#
Could you please send the copy of EOB (duplicate copy)
Home
Claim applied towards Deductible – PR 1

2 May I know the claim was processed
3 May I know the allowed amount
4 May I know what is the amount applied towards the deductible
5 May I know whether It is in-network or out of network deductible
6 May I know the annual deductible amount for the patient(in-network/out of network)
7 May I know how much deductible met so far
Home
Coins/Copay – PR 2 / PR 3
2 May I know the claim was processed
3 May I know what is the amount applied towards the copay/co-ins

6 Could you please fax/mail the duplicate EOB
No claim on file or Claim not on file

1 May I know whether Patient effective and termination date
2 If eligible-active from If not eligible-
08/01/14
3 May I know the TFL May I know whether member has any
90 days other insurance/policy with u
4 May I know the claim If yes If
mailing address 501 No
frank avenue 300
garden cit ny1530
5 May I know the EPID May I know the insurance Name,
Policy id# and Contact#
6 May I know the fax#
and whose attention
the claim should be
faxed
Eligibility for other insurance

May I know the Patient effective and termination date
If eligible- If not eligible-
May I know the TFL May I know whether member has any other
insurance/policy with u
May I know the claim mailing If yes If No
address
May I know the EPID May I know the insurance Name, Policy id# and
Contact#
May I know the fax# and
whose attention the claim
should be faxed
May I know the call ref#
Home
Claim denied as Member not eligible at the time of service

1 May I know whether the Patient effective and termination date
2 If eligible- If not eligible-
3 As per the policy effective and May I know whether member has any
termination date this dos is eligible could other insurance/policy with u
you please check that and Send the
4 If yes If
claim back for reprocess.
No
5 May I know the insurance Name,

6
Check Eligibility for other insurance
Home
Claim denied as Member coverage terminated or Policy Termed – PR 27

1 May I know whether the Patient effective and termination date
2 If eligible- If not eligible-
3 As per the policy effective May I know whether member has been renewed
and termination date this his policy. If yes get the effective from
dos is eligible could you
4 May I know whether member has any other
please check that and Send
the claim back for
5 reprocess. If yes If No
6 May I know the insurance Name,
Follow the protocol to check Eligibility for other insurance
Home
Claim denied for COB or Co-ordination of benefits – Denial Code CO 22

3 May I know whether any letter sent to patient
If Yes If No
4 May I know when the letter was sent to patient Could you please send a letter to
patient
5 Is there any response from the patient
If Yes If No
6 Could you please send the claim back for Could you please send one more
reprocess letter to patient( Client specific)
Home
Claim denied as Member enrolled in HMO/MCO

2 May I know the claim denied date
3 May I know the HMO/MCO insurance Name, id#, Contact#( if not available in the
application) else

Call HMO/MCO insurance and Check the Eligibility of the member

May I know the Patient effective and termination date
insurance/policy with you
May I know the claim mailing If yes If No
address
May I know the EPID May I know the insurance
Name, Policy id# and Contact#
May I know the fax# and whose
attention the claim should be
faxed
Home
Claim denied for Lack of information which is needed for adjudication – Denial Code CO
16
2 May I know the claim was denied
3 May I know what information is required to process the claim
4 May I know from whom the required information is needed whether patient/provider
5 May I know whether any letter sent to patient/Provider
6 If Yes If No
7 May I know when the letter was sent to Could you please send a letter to
patient/provider patient/Provider
8 Is there any response from the
patient/provider
9 If Yes If No
10 Could you please send the claim back for Could you please send one more
reprocess letter to patient/Provider( as per
Client specific)
Home
Claim denied for Offset in Medical biling

1 May I know when the claim was processed
3 May I know the amount applied towards offset
4 Is there any Patient responsibility
6 May I know to which patient is applied for offset
7 May I know the patient account# , DOS and CPT

8 May I know the reason for applied Offset adjustment
Home
Claim denied for Capitation

1 May I know when the claim was processed
2 May I know the capitation period( contract effective and termination date)
4 Is there any Patient responsibility
5 May I know whether this procedure is covered under Capitation or FFS
If FFS If Capitation
Could you please send the claim back for reprocess
Home
Claim denied for Maximum benefit met – PR 35

1 Date when the claim was received.
2 Date when the claim was denied
3 May I know the Maximum Benefit amount for the patient
4 May I know the date when the Maximum benefit amount reached
6 May I know the Call ref#
Home
Claim denied for W9 form

2 Date when the claim was rejected/denied
3 Need to check what is the address they have in their system and tax id
4 Need to get the address where the W9 form has to mailed or get the fax number and
to whom attention the w9 form has to be sent..
5 What is the time frame to submit the requested information..
6 May I know the Claim#
7 May I know the Call ref#
Home
Claim denied as Maximum frequency reached

3 May I know the maximum frequency for the procedure code
4 May I know the date when maximum frequency reached

6 May I know the call reference#
7 Could you please fax/mail the Duplicate EOB( If it is more than 30 days from the dnd
date
Home
Claim denied for Primary EOB or Explanation of Benefits

3 May I know the Primary insurance Name, id#, Contact#( in application if primary ins not
found) else
4 May I know the appeal limit and appeal address
5 May I know the fax# and whose attention claim should be faxed
Home
Claim denied for Medical Records

3 May I know why you required Medical Records for this service
4 May I know what type of Medical Records required to process the claim
5 May I know the appeal limit and address
6 May I know the fax# to fax the claim with MR notes and whose attention it should be
8 May I know the Call reference#
Home
Claim denied for Authorization in Medical billing

1 May I know the claim received date
2 May I know the claim denied date 06/16/2017
3 May I know why you required authorization for this service/cpt code the
provider is ouun
4 May I know whether you have any authorization# on your file
5 Could you please check in the hospital claim whether you have any
authorization
6 May I know whether this service is covered in that authorization
7 May I know the effective and termination date for that authorization
If yes If No
Could you please Can we get the retro authorization for this service
send the claim back
If yes If No
for reprocss with
that authorization Get the retro auth and ask whether we can submit
them to send the claim claim with MR notes
back for reprocess with

that auth# else
May I know the time limit
to get the retro
authorization
9 May I know the fax# and whose attention it should be faxed
Home
Claim denied for Missing/invalid/Referral authorization – Denial Code CO 15

1 May I know the claim received date
3 Do you have any referral # on your file/records else go for 6
4 May I know that referral #
5 Could you please send the claim back for reprocess for that referral#
6 May I know the PCP name, Contact#
7 May I know the appeal limit and appeal address
8 May I know the fax# and whose attention it should be faxed
11 Call PCP office and get the referral# and get the effective and termination date
Home
Claim has been forwarded to pricing center

1 May I know the claim processed date
2 May I know the Name of the repricing center
3 May I know the Batch # thru which claim was sent
4 Could you please fax the Batch face sheet
5 May I the repricing center telephone# and address
8 Call Repricing Center and check the status of the claim
Home
Claim denied as Non covered Service

2 May I know the claim was denied
3 Check in the application whether we received any patient for the previous dos if yes
clarify with ins rep else next question
If Yes If No
4 Provide the information to the May I know whether the CPT code is Non Covered
rep and send the claim back for or Diagnosis code is Non covered
reprocess
May I know whether it is Patient plan or Provider
contract
Home
Claim denied for Timely Filing – Denial Code CO 29

3 May I know the Timely Filing Limit
4 Check whether the claim is filed within the Filing Limit and received insurance within
the filing limit
5 If Yes If No
Clarify with insurance rep why they denied the Can we appeal with POTF
claim and send the claim back for reprocess
6 Appeal Limit and appeal address and appeal Fax# and attention to
Home
Claim denied as Past Appealing Limit

1 May I know the appeal received date
3 May I know the appeal limit
4 Check in the system whether the appeal was sent within the apealing limit.
5 If Yes If No
Clarify with insurance rep why they denied the Can we appeal again
claim and send the claim back for reprocess
6 May I know the Appeal Limit and appeal address and appeal Fax# and attention to
Home
Claim denied as Care may be covered by another payer, per co-ordination of benefits-
COB Denial Code CO 22
3 May I know whether you are acting as primary/secondary/tertiary
Primary Secondary Tertiary
4 clarify with insurance why they May I know the Primary May I know the
denied and send the claim back insurance Name, id#, secondary insurance
for reprocess Contact# Name, id#, Contact#
Home
Claim denied as Not covered by this payer or contractor – OA 109

3 May I know the HMO insurance name, id#, contact#, mailing address.
Home
Voice Mail
Hi my name is xxxxx, I am with provider “xxxxxxx” checking on claims/bill status for the
patient ” xxxxx” for the Date of Service”xxxx” for the billed amount “$xxxx”. My Call back# is
“xxx-xxx-xxxx”. Again I repeat my name is xxxxx call back# is “xxx-xxx-xxxx”. I will be
expecting your call. Thank you very much have a wonderful day.
Home
Claim denied as Global in Medical Billing

3 May I know to which procedure code it is global
4 May I know the date of service( which is applied global)
5 May I know the global days for the procedure
If DOS<=global days If DOS >global days
6 Can we appeal with modifier Clarify with insurance rep
that after the global days
If yes If No
only the service was
7 May I know the appropriate Can we appeal with performed and send the
modifier for the procedure Medical Records claim back for reprocess
code. If rep provides then Call
Appeal Limit and
telephonic re-opening line
appeal address and
update the modifier and send
appeal Fax# and
the claim back for reprocess
attention to
Home
Claim denied as Inclusive or Bundled or Mutually exclusive

3 May I know to which procedure code it is inclusive/bundled/mutually exclusive
4 May I know to which date of service
5 Can we appeal with modifier
If yes If No
6 May I know the appropriate modifier for the Can we appeal with Medical
procedure code. If rep provides then Call telephonic Records
re-opening line update the modifier and send the
Appeal Limit and appeal
claim back for reprocess
address and appeal Fax# and
attention to
Home
Claim denied for Non participating provider

4 May I know whether the given tax-id is valid for the provider or not
5 Check on dos whether provider is In-network or Out of Network
6 May I know whether patient having an out of network benefits
Home
Claim denied for incorrect Place of Service

3 May I know the correct place of service for the procedure
4 May I know the appeal Limit and appeal address and appeal Fax# and attention to
Home
Claim denied as Missing or invalid or incomplete Modifier

3 May I know to which modifier is invalid/incomplete( if modifier submitted
more than one)
4 May I know the appropriate modifier for the procedure
5 If Rep provides If not provides
Call telephonic re-opening line update May I know the appeal Limit and
the modifier and send the claim back appeal address and appeal Fax#
for reprocess( Medicare) and attention to
Home
Claim denied as Missing or invalid or incomplete CPT code

3 Check in application for previous DOS whether we received any payment for same CPT
4 If yes If No
Clarify with insurance and send May I know whether the Procedure code invalid for
the claim back for reprocess the Patient Age else
May I know whether the Procedure code invalid for
the Patient Sex else
May I know whether the Procedure code invalid for
the DOS
May I know the appeal Limit and appeal address and
appeal Fax# and attention to
Home
Claim denied as Missing or invalid or incomplete Diagnosis code

3 Check in application for previous dos whether we received any payment for same
diagnosis code
If yes If No
4 Clarify with insurance and May I know whether Diagnosis invalid for the Patient
send the claim back for Age else
reprocess
May I know whether Diagnosis invalid for the Patient
Sex else
May I know whether Diagnosis invalid for the DOS
May I know the appeal Limit and appeal address and
appeal Fax# and attention
Home
Claim denied as Patient enrolled in Hospice

3 May I know the start and End date in Hospice
4 If the dos is not in the Hospice period then call ins and send the claim back for
reprocess and go to step 6 else
5 Can we appeal with modifier
If yes If No
6 May I know the appeal Limit and appeal address May I know the Hospice Name
and appeal Fax# and attention to and address and contact#

Call Hospice insurance and check the eligibility
Home
Missing/invalid HCFA/CMS-1500
2 May I know the claim denied/rejected date
3 May I know what information is missing in the HCFA/CMS-1500
4 May I know to which field the information is missing/invalid in CMS-1500
5 If you have the required information check with insurance rep whether they can
update that information,send the claim back for reprocess then go to step 7
6 May I know the appeal Limit and appeal address and appeal Fax# and attention to
Home
Fax Back Services

1 Enter the Provider Tax-identification#
2 Enter the Patient Policy #
3 Enter the DOS
4 Enter the our Fax#
Home
Claim denied as Not Medically Necessary

3 Check whether the CPT is not medically necessity or Diagnosis code is not medically
necessity
4 Can we appeal with Medical Records
6 May I know the fax# to fax the claim with MR notes and whose attention it should be
Home
Checking Eligibility of Insurance

May I know whether member effective and termination date
May I know whether you are acting as
primary or secondary
May I know the claim mailing address If yes If No
May I know the EPID May I know the insurance

Name, Policy id# and
May I know the fax# and whose attention
Contact#
the claim should be faxed
Home
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11/12/21, 12:14 PM Denials in Medical biling and Actions-AR Denial Management 2021

Medical Billing Denials and Actions Categories

Missing/Invalid CPT code

Claim Paid Primary Insurance and Secondary

Claim denied as Primary Paid Maximum / Primary

application, if it is less than the sec allowable then

Claim denied as Patient cannot be identified as our insured – Adjustment Code – PR 31 in

Claim denied as Duplicate Claim/Service – Denial Code OA 18 / CO 18 in Medical Billing

Claim applied towards Deductible – PR 1

4 May I know the claim#

No claim on file or Claim not on file

Eligibility for other insurance

Claim denied as Member not eligible at the time of service

5 May I know the insurance Name,

Check Eligibility for other insurance

Claim denied as Member coverage terminated or Policy Termed – PR 27

Follow the protocol to check Eligibility for other insurance

Claim denied for COB or Co-ordination of benefits – Denial Code CO 22

Claim denied as Member enrolled in HMO/MCO

4 May I know the claim#

Call HMO/MCO insurance and Check the Eligibility of the member

Claim denied for Offset in Medical biling

7 May I know the patient account# , DOS and CPT

Claim denied for Capitation

Claim denied for Maximum benefit met – PR 35

Claim denied for W9 form

Claim denied as Maximum frequency reached

5 May I know the claim#

Claim denied for Primary EOB or Explanation of Benefits

Claim denied for Medical Records

Claim denied for Authorization in Medical billing

back for reprocess with

Claim denied for Missing/invalid/Referral authorization – Denial Code CO 15

Claim has been forwarded to pricing center

Claim denied as Non covered Service

Claim denied for Timely Filing – Denial Code CO 29

Claim denied as Past Appealing Limit

6 May I know the call ref#

Claim denied as Not covered by this payer or contractor – OA 109

Claim denied as Global in Medical Billing

Claim denied as Inclusive or Bundled or Mutually exclusive

Claim denied for Non participating provider

Claim denied for incorrect Place of Service

Claim denied as Missing or invalid or incomplete Modifier

Claim denied as Missing or invalid or incomplete CPT code

Claim denied as Missing or invalid or incomplete Diagnosis code

Claim denied as Patient enrolled in Hospice

7 May I know the claim#

Fax Back Services

Claim denied as Not Medically Necessary

Checking Eligibility of Insurance

May I know the EPID May I know the insurance

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Copyright © 2021 Everest Vision. All rights reserved.

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