Claims Denial Management – In and Out of Network (OON)

Category: Education

Presentation Description

Managing denials continues to be a thorn in the side of just about every healthcare organization. Many traditional approaches to denial management are no longer effect today and treat the symptom rather than the underlying causes – and the back-and-forth with payers can lead to frustration. This webinar will go through the detailed denial workflow for both In and Out of Network (OON).


Presentation Transcript

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OBJECTIVES • Identify denial trends • Work denials quickly and efficiently • Determine whether appeal is necessary • Feel confident in appeals processes • Implement strategies to reduce payer denials

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TYPES OF DENIALS • Front end edits: • Also called “Unbilled” “Code correct” “Pending with errors” • Clearinghouse edits: • Also called “exclusions” “clearinghouse rejected” • Denials • EOB denials ERA reports

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FRONT END DENIALS 1. Demographic info 2. Internal coverage dates ex policy termed 8/31 3. Authorization info 4. NDC and quantity 5. Referral referring NPI 6. General coding guidelines 7. ICD10 verification

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CLEARINGHOUSE DENIALS • Coverage more definitive • Subscriber info DOB address ID • Provider credentialing • Referrals • Authorizations • ICD 10 errors unspecified etc. • MSP Medicare

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EOB DENIALS • Coverage and COB • Authorization and referrals • Global period • Medical Necessity • Non covered benefits • Medical Records needed • Non Par OON • Duplicate • Claim lacks info

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• CO-96 Non covered charges ✓ Consult plan benefit documents/guidelines for information about restrictions for this service. Check with payer if patient may be billed • CO-18 Duplicate ✓ Confirm whether claim has been paid or previously denied. Work off initial processing • PR-27 Coverage termed CO-22 COB PR-31 Patient cannot be identified CO-24 covered under capitation ✓ Verify coverage with patient and payer ✓ Watch for replacement plans

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COMMON DENIAL EXAMPLES CONT. • CO-196 PA exceeded CO-197 PA absent CO-39 PA denied when requested CO-15 PA missing or invalid ✓ Verify Pre authorization CPT ICD10 dates etc. • CO-50 Non covered services not “medically necessary” ✓ Review LCD NCD guidelines diagnosis codes documentation • CO-16 Claim/Service lack info which is needed for adjudication ✓ Look to remark codes for additional info. Contact payer for more info if needed

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COMMON DENIAL EXAMPLES CONT. • CO-29 Timely filing limit has expired ✓ Review submissions to verify if claim was sent timely. If not appeal with reasons for late submission • CO-252 An attachment/other documentation is required to adjudicate this claim/service ✓ Submit with documentation in the future send upon first submission • CO-234 Procedure not paid separately CO-97 benefit included in another adjudicated service ✓ Check NCCI edits and plan guidelines. Add modifier if appropriate

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