Wiki Adjustment Reason Code 107

[eharloff]

I am so confused on what this ARC means. This was sent back to me by Blue Care Network (part of BCBS of MI)...
I billed a TCM (99496) and Medication Reconciliation (1111F). The claim was processed without payment due the following:
CO-107: The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1. Where do I find this Policy?
2. What exactly does this mean - do I need to send medical records of the patient's visit?

I've tried researching on my own via Google, Medicare, BCBS, etc., but really cannot get a straight answer on what I'm supposed to do. I did read something about an add-on code, but there is not an add-on code that's warranted for any codes used. Primary code is Z09.

I would appreciate some insight on this and what you've done in the past! Thank you! )

 

[sls314]

I am so confused on what this ARC means. This was sent back to me by Blue Care Network (part of BCBS of MI)...
I billed a TCM (99496) and Medication Reconciliation (1111F). The claim was processed without payment due the following:
CO-107: The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

1. Where do I find this Policy?
2. What exactly does this mean - do I need to send medical records of the patient's visit?

I've tried researching on my own via Google, Medicare, BCBS, etc., but really cannot get a straight answer on what I'm supposed to do. I did read something about an add-on code, but there is not an add-on code that's warranted for any codes used. Primary code is Z09.

I would appreciate some insight on this and what you've done in the past! Thank you! )

The policies may be on Availity with the BCN provider manuals, perhaps? https://www.bcbsm.com/providers/resources/manuals/

Here's some info I found from BCN about transitional care management as it relates to HEDIS measures https://www.bcbsm.com/amslibs/conte...tar-measure-tip-sheet-transitions-of-care.pdf

(I know it isn't the full policy on TCM, but it still might give you some insight on what type of documentation they might want to see.)

Good luck!

 

[eharloff]

The policies may be on Availity with the BCN provider manuals, perhaps? https://www.bcbsm.com/providers/resources/manuals/

Here's some info I found from BCN about transitional care management as it relates to HEDIS measures https://www.bcbsm.com/amslibs/conte...tar-measure-tip-sheet-transitions-of-care.pdf

(I know it isn't the full policy on TCM, but it still might give you some insight on what type of documentation they might want to see.)

Good luck!

You're a life saver! I couldn't find anything - maybe I was just overlooking it. I will look into those. Appreciate you

 

[tkaczmarek]

CO-107: The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

I have found this denial with many insurances for TOC billing. It happens when the TOC bill is received by the insurance before receiving the hospital inpatient bill or the hospital not billing an inpatient stay, but outpatient instead.

I will usually follow up with the payer to see if they have received the hospital inpatient bill by the time we have their denial. Most often the insurance has received the corresponding inpatient bill and can send your TOC claim to reprocess for payment. There have been times though, that depending on the facility, it can take months for an insurance to receive the hospital bill. OR, I have had hospitals bill for outpatient services when the hospital documentation clearly shows an admission. I have a local insurance company that has gone back to the hospital system to review the billing and we have had our TOC claim paid because the patient was truly admitted.

Many scenarios but that is the nature of that denial verbiage. Hope this helps!

 

[eharloff]

CO-107: The related or qualifying claim/service was not identified on this claim. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

I have found this denial with many insurances for TOC billing. It happens when the TOC bill is received by the insurance before receiving the hospital inpatient bill or the hospital not billing an inpatient stay, but outpatient instead.

I will usually follow up with the payer to see if they have received the hospital inpatient bill by the time we have their denial. Most often the insurance has received the corresponding inpatient bill and can send your TOC claim to reprocess for payment. There have been times though, that depending on the facility, it can take months for an insurance to receive the hospital bill. OR, I have had hospitals bill for outpatient services when the hospital documentation clearly shows an admission. I have a local insurance company that has gone back to the hospital system to review the billing and we have had our TOC claim paid because the patient was truly admitted.

Many scenarios but that is the nature of that denial verbiage. Hope this helps!

I was initially wondering that at first! It's currently going through reconsideration but will follow-up and see if that's possibly the reason. Appreciate your input!

 

[c_selinsky]

I always call the payer and ask questions usually there is a more complex reason they are denying, for example I work in a Retina Surgery center, Excellus denied with a 107, I called to find out what the true issue was at first the rep told me that it was medical records that they needed upon further review because we have already sent records, Excellus was looking for us to complete step therapy for this patient, I never trust a 107 I always call and ask what the real reason is