We’ve dug into most prevalent denial reason codes in these unbelievable times to shed light on solutions that help your practice avoid expensive denials. Claims denials are widespread, and they have a considerable impact on your bottom line. We’ve compiled a list of the top five most common denial reason codes and provided solutions to help you decrease the number of denials that come back to your practice.
Denial Code CO 11 – Inconsistent Diagnosis with Procedure
It’s not unusual to see a denial stating that the diagnosis code was incompatible with the process coded in the claim. The diagnosis code describes the health condition and must be consistent with the process or services provided to a patient.
In many situations, denial code CO 11 occurs due to a simple coding error in which the incorrect diagnosis code was used. If you receive this type of rejection, the first thing you should do is check your email. Verify with the coding department and the patient’s document to ensure there would not be a typing error or that a diagnosis was accidentally left out. If there were an error, you would need to rectify the claim and resubmit it as a fixed claim. If there was no mistake, but you assume the denial is incorrect, you can appeal the claim and provide health records that support the medical reason of the process for this patient’s condition.
Denial Code CO 27 – Expenses incurred after the coverage terminated
Denial Code CO 27 happened when costs were imposed after the patient’s coverage was terminated, implying that your practice offered health care services to a patient after their insurance claim was canceled. Because these denials are challenging to counter, your primary goal should be to avoid them. This includes verifying your patients’ insurance benefits before offering services so that your office is aware of whether your patient’s insurance coverage has been aborted or is still operative. Front-office personnel should confirm insurance for every visit, allowing you to either get the most up-to-date insurance details or determine whether the individual is a self-pay patient.
If you receive a denial code CO 27, double-check the policy’s end date. Then, you can see if the patient had any other insurance plans in effect when you offered services. If not, you will have to bill the patient directly.
Denial Code CO 22 – Coordination of benefits
When a patient has numerous payers, coordination of advantages rules determines which payer is the primary, secondary, and tertiary insurance to ensure the correct payers pay and no repetition of payments. When filing a claim, the primary insurance must be contacted first. The remaining balance is then submitted to the patient’s secondary or tertiary insurance companies to avoid denial code CO 22. Some of the most common reasons for benefit denial coordination include:
- A misplaced estimate of benefits.
- Another type of insurance is regarded as primary.
- The member has not provided the insurer with up-to-date insurance information.
When this form of denial occurs, your first step should be to qualify and which of their insurances is primary. Then you’ll know how to offer up the claim to the appropriate insurer. In some instances, this may happen because payers are unsure which insurance company is primary, secondary, etc. That means that the member must be alerted, and the payers must be upgraded before the coordination of advantages can be modified and the claim resubmitted as needed.
Denial Code CO 29 – The Timely Filing
All payers have time restrictions for filing claims and assume them to be submitted on time. When claims are not forwarded within this time frame, they are rejected with the denial code CO 29 for submitting a claim after the time limit has expired. Because you’ll most likely be working with several insurance carriers, make sure you’re conscious of each of their prompt filing deadlines, as they can vary. Here are a few common examples of timeline filing deadlines:
- Aetna-Unless exceptional cases or state law apply.
- Hospitals have one year from the date of service to file a claim.
- Physicians have 90 days from the date of service to file a claim.
- Cigna-Unless exclusions or state law apply.
- Out-of-network suppliers have 180 days from the service date to file a claim.
- Participating suppliers have 90 days from the service date to file a claim.
- TRICARE – Claims must be submitted within a year of the date of service.
- United Health Care- Provider agreements are included in the specified timeline filing restrictions.
Denial Code CO 167 – Diagnosis is not included
Finally, CO 167 is a denial code used when the payer does not encompass the diagnosis. If you come across this denial code, go over the diagnosis codes in the claim. If you forwarded multiple diagnosis codes, it might be helpful to notify the payer to evaluate which code they claim is not captured. Then you can decide whether another diagnosis code or a combination of diagnosis codes should have been used. Check if the diagnosis codes have been rectified, then resubmit the claim as a corrected claim or bill the patient for the offerings or processes.
Learning more about some of the most common claim denials allows your practice to understand how to avoid those denials that can reduce profits. Our medical billing specializes in assisting medical procedures across the country in increasing revenue and performance. If you’d like to learn more about how you can prevent refusals, increase practice efficiency, and improve your bottom line, contact firstname.lastname@example.org today.
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