REIMBURSEMENT SUCCESS

Chapter 13


REIMBURSEMENT SUCCESS



Objectives


After completing this chapter, you should be able to:


image Organize and track financial documentation for the medical office


image Make decisions that result in correct payments from payors and patients


image Read and interpret an EOB/EOMB/MRN


image Compare payments received with fee schedules


image Determine when to rebill a service provided and when to file an appeal


image Gather the documents needed for a retrospective payment audit



Key Terms



adjustment codes


codes used by payors to explain why a claim or a service is paid differently than it was billed.


aging reports


reports used to report the status of claims to the physician and to identify individual transactions that require follow-up.


bad debt write-off


a write-off that records payments owed, but not collectable. It does not represent a discount.


case number


a payor-assigned number that must appear on each page of each document sent with an appeal.


concurrent payment audit


an audit that occurs at the time payments are posted to evaluate the correctness of payments received on the day of the audit.


electronic payment posting


the payor automatically posts a payment to your practice management system after making an automatic deposit into the practice bank account.


electronic remittance voucher


an electronic EOB (explanation of benefits) that is sent when the payor sends an electronic payment that is automatically deposited in the practice bank account.


explanatory notes


these give additional information about items referenced by footnotes or symbols on an EOB.


financial hardship discount


a discount given when a patient is in financial difficulty and cannot meet the patient financial obligation. A hardship waiver must be on file before this discount is given. The physician collects the payor’s portion of the charge and writes off the patient portion of the charge.


financial policy statement


a patient-signed document that protects the physician’s right to collect money earned.


insurance write-off


the insurance discount given to a payor in a contract.


ledger card


an old-fashioned patient accounting method that does not allow you to track payments by transaction.


line item posting


an accounting method by which every payment is posted to the exact transaction for which the payment is received.


patient discount


a discount often offered to self-pay patients if they pay their bills on time. It must not cause the total fee to become lower than the Medicare fee schedule for the service.


patient eligibility


the process of contacting each payor and verifying that the patient is covered by the policy, the policy information is correct, and the policy has not expired. Sometimes additional information is needed to determine the primary payor for the claim.


professional courtesy


the physician sees a patient at no charge.


reimbursement decision tree


a tool to help you decide what your next action is when you receive an EOB from a payor.


retrospective payment audit


an audit that tracks and evaluates patient financial records for a specific number of completed transactions. It verifies the correctness of payments received from every source and the correctness and appropriateness of the write-offs for each transaction.



Introduction


The reimbursement process follows the lifecycle of the medical insurance claim. It begins when the patient first requests an appointment, and it ends when full payment is received and the paperwork is complete.


The single greatest obstacle to correct reimbursement is fragmentation in the billing process. Fragmentation occurs when medical office employees do not work together as one team. Employee errors can occur repeatedly when employees do not share information and therefore do not learn from past mistakes


The greatest reimbursement success occurs when employees do work together as one team to oversee the claim cycle from start to finish. In a team environment, a billing problem is everyone’s problem. Team meetings allow the sharing of information. The team works together to identify the causes of problems and to devise methods to prevent recurrences. The entire team is responsible for failures and for successes, and everyone shares in the accomplishment of getting the office paid.


Billing and collections directly influence one another. Even in the best team environment, billing and collections should not be separated into different positions. When you receive and post payments for every claim you personally send, you read the information codes on every explanation of benefits (EOB) form that accompanies the payments. You will quickly learn billing preferences for each payor, and you can adjust your internal procedures to match payor-specific requirements. Important trends are often missed when different people perform these functions and they do not share information.


Even in large practices, the billing department can be structured so every billing employee performs both the billing and collections functions for specific claims. In one setup, each employee is assigned to work with smaller teams organized around specific providers. In another setup, each employee is assigned to work with smaller teams organized around specific payors. In yet another setup, each employee is assigned a range of patient last names, using the alphabet to divide patients evenly between the billing employees.


In this chapter you will learn how to verify patient eligibility, interpret payment documents, determine what steps to take next in a variety of situations, appeal claims, and follow through and complete the claim cycle for both simple and complex claims.



The Reimbursement Process


The lifecycle of a medical claim was first introduced in Chapter 3 to give you an overview of the claim process and to lay the groundwork for the remainder of the process. A single-payor “clean” claim was used as an example in Figure 3-1 in Chapter 3.


Let’s begin our discussion of the reimbursement process in this chapter by taking another look at the lifecycle of the medical claim, but this time we’ll expand the discussion to include other payors and to include the additional cycles that occur when a claim is not error free (Figure 13-1).


image
FIGURE 13-1 This expanded lifecycle of the medical claim includes secondary and tertiary payors, and it includes rejected and penalized claims. The single-payor, clean-claim portion of the lifecycle has a white background, the extra twists for additional payors have a colored background, and the extra cycles for claims that are not clean (rejected or penalized claims) have a gray background.


SCHEDULER


The medical claim cycle begins when the patient requests an appointment. In addition to scheduling the appointment with an authorized provider for the patient’s medical plan, the scheduler begins to gather or verify patient-supplied claim information and sometimes information for preauthorization when needed for the appointment. Your work as a scheduler does not end at the conclusion of the telephone call.


In most offices, it is a standard policy to contact each payor and verify that the billing information is correct and the policy or patient eligibility has not expired. This is called verifying patient eligibility. It is done so a clean claim can be sent to the correct payor when the patient incurs billable charges.



Some payors are beginning to offer secure websites and “participating” providers are given free software or passwords that enable employees to verify eligibility and preauthorizations instantly over the Internet. Not every payor offers this capability, and payors that offer it in some regions might not offer it in every region. In addition, there are now sites, such as WebMD, that allow an office to access multiple payors from one site. There may be a monthly membership fee for this service.



When a procedure is scheduled and/or when you work for a specialist, you must ask the payor about preauthorization requirements for the provider. Next, you must determine whether you need to obtain preauthorization for the procedure or for the location of the service. You could need as many as three different authorizations from each payor, and there will be times when you need to call the referring provider to initiate or confirm each authorization. This process often takes a few days, and occasionally it takes a few weeks. Therefore you should begin to verify preauthorizations as soon as possible after the appointment is scheduled. Every preauthorization must be verified before the patient receives services if you want the resulting claim to be considered for payment.



When preauthorization is not obtained before performing a service that requires preauthorization, the payor does not have to pay the claim. The payor’s computerized edit and audit process is sometimes programmed to automatically deny payment. However, many payors make it a policy to penalize the payment, thereby paying a smaller amount instead of issuing a direct denial.


Obtaining a preauthorization only means the claim will be considered for payment; the preauthorization does not guarantee payment. The payor will also look at the diagnosis codes billed on the resulting claim for the service to see if they explain why the service was needed. This process is called meeting medical necessity. Payors do not pay for services that are not medically necessary.




RECEPTIONIST


As patients arrive for their appointments, the receptionist gathers patient-supplied billing information for new patients and confirms this information for existing patients. The receptionist checks for the completion of any required preauthorizations. The receptionist obtains patient signatures for release of information and assignment of benefits and makes photocopies of both sides of the insurance card and driver’s license for every patient.


When the medical plan is a TRICARE/CHAMPUS program, the receptionist also makes a photocopy of both sides of the military ID card with a “Yes” under “Civilian” to authorize civilian benefits. The military ID must not be expired. In addition, a nonavailability slip is required for inpatient hospital services when the patient lives within 40 miles of a military hospital. A nonavailability slip is issued only if treatment is not available in the military treatment facility near the patient’s home or if the patient is away from home. See Chapter 11 for further details about TRICARE/CHAMPUS requirements.



If you cannot obtain a legible photocopy of one or more of the IDs, you must handwrite the information from the insurance card, driver’s license, or military ID onto the photocopy in a clear space near the applicable ID.



It is the responsibility of the receptionist to verify patient eligibility and to determine all possible payors. When the information already on file is inadequate to verify eligibility before the appointment, the receptionist must gather additional information during check-in. See Figure 13-2 for a tool you may use to assist in determining eligibility. It is up to office policy whether you ask the questions verbally or whether you ask the patient to complete the form.


image
FIGURE 13-2 Insurance eligibility questionnaire. (Courtesy Medical Compliance Management, Inc., Orlando, Fla.)

The eligibility questionnaire provides enough information to determine the primary payor. However, as Medicare has complex rules, you may want also to develop a decision chart to help you determine whether Medicare is the primary or the secondary payor in a wide variety of special circumstances. See Figure 13-3 for an example of a Medicare decision chart. As Medicare requirements change, revise your chart to illustrate the new requirements.


image
FIGURE 13-3 A Medicare decision chart is used to determine whether Medicare is the primary or secondary payor in a wide variety of special circumstances. As Medicare requirements change, revise the chart to illustrate the new requirements. (Courtesy Medical Compliance Management, Inc., Orlando, Fla.)

Most payor contracts also define coverage restrictions for various situations. For example, many payors do not cover care for service-connected disabilities that are covered by the VA, and they do not cover care for work-related injuries that are covered by workers’ compensation. Therefore you might want to create a similar decision chart to relate information from your payor contracts for each of your major payors. This tool can be used together with the managed-care chart introduced in Chapter 3 (see Figure 3-15) to meet payor-specific billing and collection requirements for each patient.


As a receptionist, you are responsible for entering new information into the computer correctly and, when necessary, correcting inaccurate information. You must double-check all patient identifiers, including birthdays. You also must double-check the preauthorization requirements. If an authorization was denied or if you have any reason to suspect the payor might not cover the service, you should disclose this to the patient and get a written statement confirming payment responsibility in the event the payor denies payment. Examples of a variety of Medicare Advance Beneficiary Notices (ABNs) and consent forms are found in Chapter 3, Figures 3-6 through 3-9. You may use these examples to create similar forms for use with other payors.






BILLERS AND CODERS


Next, the billing department is given the superbill. Billing and coding personnel once again verify both the patient-supplied billing information and the provider-supplied billing information as they code the services and prepare the claim. See Chapter 4 for detailed claim preparation instructions.


The primary payor is the insurance company to be billed first when more than one insurance company can be billed, and the secondary payor is the insurance company that is billed for any remaining unpaid bills after the primary payor has sent payment. When a third payor exists, the payor that is billed third is called the tertiary payor. The tertiary payor pays any remaining unpaid bills after the secondary payor has sent payment. The biller is usually held accountable for making the final determination about which payor is primary. Failure to identify the correct primary payor is considered a violation of most provider contracts or agreements and is usually considered a breach of trust.


Each employee in the reimbursement chain is part of the reimbursement team and must perform his or her job correctly. The quality and accuracy of billing information and clinical documentation, as it flows through each department and is entered on the claim form, has the single greatest impact on the profit margin for the claim.


When complete, the medical claim is submitted to the payor either electronically or by mail. Payment is received a little faster with electronic submission of claims, usually in about 10 days, and electronic submission eliminates the potential for data entry errors when the claim reaches the payor. Paper claims that meet optical character recognition requirements and can be scanned into the payor’s computer are usually processed and paid in about a 3-week cycle. Paper claims that cannot be scanned are usually processed and paid in about an 8-week cycle.


The patient is not billed unless a “patient responsibility” balance remains after all identified payors have sent the correct reimbursement for the claim.




PAYOR


Once the claim reaches the payor, a record of the transaction is established by the payor, and the stage is set for the remainder of the claim cycle. When an initial claim reaches the payor, it is automatically subjected to a series of claim edits and claim audits established by the medical plan. Claim edits verify the completeness and accuracy of information entered on the claim form. Claim audits check for duplication of services or billing that is in excess of normal.


“Excess of normal” means the payor compared the nature of the presenting illness and the linked diagnosis to each service provided and found a higher level of visits than normal, more visits than normal, or a more complex procedure than normal.


If the claim is clean and passes the payor edits for obvious mistakes, then the payor audit process begins. For physician and outpatient claims, the physician’s diagnoses are linked to the procedures billed, and this information is used to determine whether medical necessity was met so the payor can authorize payment. For inpatient hospital claims, the principal diagnosis and DRG group billed are compared to the services provided to determine whether medical necessity was met so the payor can authorize payment. Sometimes the payor requests a copy of the medical record documentation for the visit. Then the nature of the presenting illness and the physician’s findings may also be considered. If the claim is still clean and it passes all the payor audits as well, a payment amount is determined and payment is sent to the physician, either electronically or by mail.


If the claim is “dirty” and does not pass all of the payor edits and audits, one of the following events is likely to occur: (1) the claim is either rejected or denied and no payment is sent, or (2) the claim is processed and penalties are applied, reducing the amount of payment that is sent.



COLLECTIONS: POSTING PAYMENTS AND ADJUSTMENTS


An EOB is sent either electronically or by mail to the physician for every claim received by the payor. When payment is authorized, the payment is either deposited electronically into the physician’s bank account or it is enclosed with the EOB. The remarks on the EOB and the amount paid are the first indications of whether follow-up procedures are required for the claim.


When the full payment amount due from the payor is received and verified, a collections employee posts the payment. If secondary insurance is responsible for an additional amount or if the patient has an outstanding balance for his or her portion, the account for this transaction (claim) remains open. When no further payment is expected, the account is closed, and a record of the transaction remains on file for the time specified in the payor contract or the time specified in state or federal laws, whichever is longer. The longest period is usually 7 years, so most practices choose to keep all their records, both medical records and financial records, for at least 7 years.



Some organizations are lobbying to have the laws changed so patient medical records and patient financial records, including insurance records, are kept for the life of the patient or 7 years, whichever is longer.



When no payment is received or when only partial payment is received, a collections employee posts the payment (if any), but the account for the transaction remains open for further action. In most cases, the next action is to correct the claim information and either rebill the claim or file an appeal.


Note: When the primary payor did not send payment because the service is not covered by the plan, a secondary payor may be billed or the patient may be billed for any remaining “patient responsibility” amount.




PENALTIES AND APPEALS


Payor contracts usually allow the payor to reduce the payment owed for dirty claims. These are claims that provide enough correct information to process the claim, but the claims do not pass all the edits and audits, so the claims are not clean. This reduction in payment is called a penalty. Partial payment is usually sent with penalized claims, although occasionally a penalized claim receives zero payment, and once in a while, the provider owes money due to the penalty.


Penalized claims cannot be rebilled; they must be appealed. Appeals also must occur within the period established by the payor contract. The time period may be as short as 60 days from the date of the EOB or it may be as long as 2 years from the date of the EOB. Appeals obtain better results when they are submitted by mail with supporting documentation.


Rebilling claims and filing appeals are discussed in more detail later in this chapter.



CORRECTED CLAIMS



Whether filing an appeal or resubmitting a rejected claim, corrected claims always have at least one change somewhere on the claim form. Sometimes the change is accompanied by a stamped message: “resubmission” or “corrected claim.” When a claim is resubmitted with no changes, it is called a duplicate claim. Payors interpret duplicate claims as a fraudulent attempt to collect twice on the same claim. Payment is not sent for duplicate claims.



When a corrected claim is received by a payor, whether rebilled or appealed, the claim is immediately flagged for closer scrutiny. Even if the claim is now clean and can pass the payor’s standard claim edits and claim audits, claim adjusters are not authorized to make payment decisions on repeat claims, and the claim is sent to a review department.



CLAIM REVIEW


Most payor contracts have many loopholes (legal or not) that state the payor may deny or reduce payment for a wide variety of reasons. A claim review employee closely scrutinizes the claim, and every box on the claim form represents a potential reason to deny or reduce payment. Payor contract provisions often give the payor complete control and authority over claim review.


Claim review is normally performed by hand—it is not automated or computerized—and repeat claims are not subject to the payment time limits that apply to initial claims. The review process and payment decision for a repeat claim can take anywhere from 6 weeks to 6 months. Most of that time the claim just sits in a “claim review” inbox, also called a pending or suspense file, waiting to be processed. Contested claims often must go through this process at least twice before other alternatives, such as arbitration, are available.




BILLING PATIENTS, POSTING WRITE-OFFS, AND CLOSING TRANSACTIONS


After all insurance payments are received, collections employees check to see whether the patient is responsible for any of the remaining balance. Secondary and tertiary insurance payments reduce the patient responsibility amount before they reduce any physician write-off amounts from the primary payor.


More than 80% of all medical care is now subject to managed care rules and contract provisions. Most managed care contracts do not allow a provider to bill patients for anything except a deductible or copayment amount, and many payor contracts specifically stipulate that penalty amounts are not a patient responsibility. In addition, services that are deemed as “noncovered” services usually may be billed to the patient only if the patient signed a specific “Noncovered Service Payment Agreement” (or Advance Beneficiary Notice, ABN) before the service was rendered. See Figure 3-6 in Chapter 3 for an example of a Medicare noncovered service ABN.


When all expected payments from all sources, including the patient, have been received, remaining balances are typically written off, and the account for the transaction (claim) is closed. These write-offs also are called claim adjustments, and they are discussed in more detail later in this chapter. A record of the transaction remains on file for the time specified in the payor contract or the time specified in state or federal laws, whichever is longer.



Explanation of Benefits


While completing and submitting clean claims is very, very important, it is only the first segment of the reimbursement process. The next segment begins when a response is received from the primary payor.


Payors respond in writing to every claim sent. A document commonly called an EOB accompanies each payment and each denial of payment. The purpose of the EOB is to explain the payor’s payment decision. Medicare calls this document a Medicare remittance notice (MRN), although some billers call it Medicare’s remittance advice (RA).


The explanation of Medicare benefits (EOMB) is the old name for the patient statement sent to Medicare beneficiaries. The new name for Medicare’s patient statement is the Medicare summary notice (MSN).


Most payors send a separate EOB for each claim. Medicare batches the claims for each practice ID number and sends one check with a multipatient, often multipage MRN. Dividing lines separate each patient, and the payment considerations for each patient are broken down individually for each line item procedure. Medicare sometimes separates line items from a single claim into separate payment batches when some of the items are approved immediately and other items are sent to review. The MRN then identifies each item billed on the claim, and remarks codes are used to tell you which items have been sent to review. Even though Medicare’s MRN represents a batch of patients, it still supplies the same information for each patient and each procedure as the individual EOBs sent by other payors.



HOW TO EVALUATE AN EOB


When you receive an EOB or MRN, read every item pertaining to each transaction, including each explanatory note. Often footnotes or symbols are placed next to specific items on the EOB. The footnotes or symbols indicate that you should look for explanatory notes for additional information pertaining to that item. The footnotes and symbols are used to tie together the items in the EOB with the applicable explanatory notes that are usually located at the bottom of the page. Medicare’s explanatory notes are placed on the last page, after the last reported transaction.


Most footnotes are error codes or claim adjustment codes, but some convey other types of information. Error codes are sometimes very vague. “Incomplete data” or “missing data” can occur in any part of the claim form. Often when information changes in one block on the CMS-1500 claim form, it influences information in other blocks. Because the payor does not know the missing information, the payor cannot tell you in precise detail how to correct the claim. The vague phrases are intended to guide you into re-evaluating the entire claim.


You are expected to know whether a correction in one block influences information in other blocks, and you are expected to make every adjustment related to the first correction before evaluating the rest of the claim for accuracy.


Sometimes error codes are cleverly worded. “Payment is in the amount agreed to in the contract” rarely means that payment is in the amount published in the payor fee schedule. Usually this phrase means the physician agreed to accept decisions made by the payor’s utilization review (UR) or quality assurance (QA) personnel, and the UR or QA personnel applied a penalty to the claim, reducing the amount of payment. Payor research has shown that few payment decisions are challenged when payments that have been reduced by penalties or by downcoded levels of services are explained in this manner. The statement is not false, but it can be misleading.


Adjustment codes are used by payors to explain why a claim’s line item is paid differently than it was billed. Many payors use these codes for internal purposes and report vague phrases on the EOB. Individual payors may assign different numbers or symbols to these codes, and the wording may vary from payor to payor.


Table 13-1 shows a small sampling of the Health Care Claim Adjustment Reason Codes. The full list has more than 180 codes. A government committee with multi-payor representation maintains this list for the Secretary of the Department of Health and Human Services to meet the code set requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The full list of codes can be found at www.wpc-edi.com under “HIPAA, Code Lists.”



TABLE 13-1


Health Care Claim Adjustment Reason Codes










































































































Item Description
1 Deductible amount.
2 Coinsurance amount.
3 Co-payment amount.
4 The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 The procedure code/bill type is inconsistent with the place of service.
6 The procedure code is inconsistent with the patient’s age.
7 The procedure code is inconsistent with the patient’s gender
11 The diagnosis is inconsistent with the procedure.
13 The date of death precedes the date of service.
14 The date of birth follows the date of service.
15 Claim/service denied because the authorization number is missing, invalid, or does not apply to the billed service.
16 Claim/service lacks information which is needed for adjudication.
17 Claim/service denied because requested information was not provided or was insufficient/incomplete.
18 Duplicate claim/service.
19 Claim denied because this is a work-related injury/illness and thus the liability of a workers’ compensation carrier.
20 Claim denied because this illness/injury is covered by the liability carrier.
21 Claim denied because this illness/injury is covered by the no-fault carrier.
29 The time limit for filing has expired.
31 Claim denied as patient cannot be identified as our insured.
45 Charges exceed your contracted/legislated fee amount.
46 This (these) service(s) is (are) not covered.
47 This (these) diagnosis(es) is (are) not covered.
48 This (these) procedures(s) is (are) not covered.
49 These are noncovered services because this is a routine exam or screening procedure done in conjunction with a routine exam.
50 These are noncovered services because this is not deemed a “medical necessity” by the payor.
57 Claim/service denied/reduced because the payor deems the information submitted does not support this level of service, this many services, this length of service, or this dosage.
110 Billing date predates the date of service.
138 Claim service denied. Appeal procedures not followed or time limits not met.
A2 Contractual adjustment.
B2 Noncovered visits.
B4 Late filing penalty.
B5 Claim/service denied/reduced because coverage/program guidelines were not met or were exceeded.
B12 Services not documented in patient’s medical records.

Source: U.S. Department of Health and Human Services.


Figure 13-4 is an example of a generic EOB. Although each payor reports the information in a slightly different manner, the basic elements of an EOB are similar.


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FIGURE 13-4 A generic explanation of benefits (EOB). Although each payor reports the information in a slightly different manner, the basic elements of any EOB are similar.

A patient identifier is present on every EOB. Most often, the patient name is used, but a few payors use the patient account number from block No. 26 on the CMS-1500 claim form, and some use the patient-specific insured’s ID number from block No. 1a of the claim form.


The date of service from block No. 24A and the procedure code from block No. 24D are usually used together to identify each exact transaction reported on the EOB. A few payors use only the date of service.


Many payors tell you both the amount you charged for the visit and the payor-specific “allowed” amount for the claim. However, a few payors only include the allowed amount and expect you to have a record of the original charge.


Most payors provide a breakdown of the charges you may bill to the patient. This breakdown includes, but is not limited to, deductibles, copayments, coinsurance, noncovered items, and the total amount you may bill the patient. This total is provided for record-keeping purposes. It is not a mandate to send a bill to the patient. Many times a secondary payor is responsible for at least a portion of the “patient responsibility” amount from the primary payor.


The EOB also specifies the dollar amount of the contractual write-off. You may not bill the patient for an insurance discount agreed to in a payor-physician contract. However, do not be misled into believing a penalty is a contractual discount. Check the payor fee schedule and your summary of contract billing requirements to see what the allowed amount and the contractual discount for each transaction should be according to the actual contract.


If the allowed amount on the claim is less than the amount agreed to in the contract, a penalty has probably been applied to the claim. Penalties are most often applied when something on the claim was incorrect or when the service did not meet medical necessity requirements. When you find an error, you may correct it and appeal the decision. If the diagnosis codes billed did not accurately portray the encounter, you may appeal the claim and send supporting documentation that shows the actual diagnoses and complexity of decision-making.


Finally, the amount of payment is listed on every EOB. The payment represents the payor’s share of the allowed amount. The payor payment plus the “patient responsibility” total should equal the allowed amount for that payor.


Many times footnotes, codes, and symbols are present in many locations on the EOB. The legend for the footnotes, codes, and symbols is listed at the bottom of the EOB in a section commonly called “explanatory notes.” The explanatory notes convey the calculation considerations and/or other relevant information for each referenced item.


Sometimes footnotes or symbols convey other important information. Medicare often uses line level and claim level remark codes. Table 13-2 is a select sampling of the Medicare line level and claim level remark codes. The complete list of Medicare line level remark codes has 122 codes, each of which begins with “M,” followed by numbers 1 to 122. The complete list of Medicare claim level remark codes has 131 codes, each of which begins with “MA,” followed by numbers 1 to 131. Medicare also has 26 generic claim or line level remark codes, each of which begins with “N,” followed by the numbers 1 to 26.



TABLE 13-2


Medicare Remark Codes

















































































































































Item Description
M1 X-ray not taken within the past 12 months or near enough to the start of treatment.
M2 Not paid separately when the patient is an inpatient.
M12 Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim.
M13 No more than one initial office visit may be covered per specialty per medical group. Visit may be rebilled with an established visit code.
M14 No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.
M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.
M24 Claim must indicate the number of doses per vial.
M25 Payment has been (denied for the/made only for a less extensive) service because the information furnished does not substantiate the need for the (more extensive) service. If you believe the service should have been covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this (more extensive) service, or if you notified the patient in writing in advance that we would not pay for this (more extensive) service and he/she agrees in writing to pay, ask us to review your claim within six months of receiving this notice. If you do not request review, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her (for the/in excess of any deductible and coinsurance amounts applicable to the less extensive) service. We will recover the reimbursement from you as an overpayment.
M29 Claim lacks the operative report.
M30 Claim lacks the pathology report.
M31 Claim lacks the radiology report.
M33 Claim lacks the UPIN of the ordering/referring or performing physician or practitioner, or the UPIN is invalid. (Substitute NPI for UPIN when effective.)
M37 Service not covered when patient is under the age of 35.
M39 The patient is not liable for payment for this service as the advance notice of noncoverage you provided the patient did not comply with program requirements.
M41 We do not pay for this as the patient has no legal obligation to pay for this.
M52 Incomplete/invalid “from” date(s) of servive.
M58 Please resubmit the claim with the missing/correct information so that it may be processed.
M62 Incomplete/invalid treatment authorization code.
M68 Incomplete/invalid attending or referring physician identification.
M81 Patient’s diagnosis code(s) is truncated, incorrect, or specificity.
MA01 Initial Part B determination, carrier or intermediary:
If you do not agree with what we approved for these services, you may appeal our decision. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the review. However, in order to be eligible for review, you must write to us within 6 months of the date of this notice, unless you have a good reason for being late. (Carrier or intermediary may add additional remarks.)
MA03 Hearing:
  If you do not agree with the approved amounts and $100.00 or more is in dispute (less deductible and coinsurance), you may ask for a hearing. You must request a hearing within 6 months of the date of this notice. To meet the $100.00, you may combine amounts on other claims that have been reviewed/reconsidered. This includes open reviews if you received a revised decision. You must appeal the claim on time. At the hearing, you may present any new evidence that may affect our decision.
MA04 Secondary payment cannot be considered without the identity of or payment information from the primary payor. The information was either not reported or was illegible.
MA07 The claim information has also been forwarded to Medicaid for review.
MA13 You may be subject to penalties if you bill the patient for amounts not reported with the PR (patient responsibility) group code.
MA15 Your claim has been separated to expedite handling. You will receive a separate notice for other services reported.
MA29 Incomplete/invalid provider name, city, state, and zip code.
MA36 Incomplete/invalid patient’s name.
MA38 Incomplete/invalid patient’s birthdate.
MA39 Incomplete/invalid patient’s sex.
MA44 No appeal rights on this claim. Every adjudicative decision based on law.
MA48 Incomplete/invalid name and/or address of responsible party or primary payor.
MA58 Incomplete release of information indicator.
MA60 Incomplete/invalid patient’s relationship to insured.
MA83 Did not indicate whether we are the primary or secondary payor. Refer to item 11 in the CMS-1500 instructions for assistance.
MA87 Our records indicate that a primary payor exists (other than ourselves); however, you did not complete or enter accurately the correct insured’s name.
MA100 Did not complete or enter accurately the date of current illness, injury or pregnancy.
N1 You may appeal this decision in writing within the required time limits following receipt of this notice.
N3 Required/consent form not on file.
N11 Denial reversed because of medical review.
N13 Payment based on professional/technical component modifier(s).
N15 Services for newborn must be billed separately.
N19 Procedure code incidental to primary procedure.
N24 Electronic funds transfer (EFT) banking information incomplete/invalid.

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May 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on REIMBURSEMENT SUCCESS

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