835 Healthcare Policy Identification

mamador2

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Okay, please don't post a link to lists of vague medicare denial codes, I've read through the PDF's I could find on google already and they weren't very helpful to me. I'm looking for a simple plain english definition of what the heck 835 Healthcare Policy Identification Segment denial code actually means, and what loop 2110 REF is and where to find these things I'm supposed to be able to refer to. I've attached an example of a common 835 denial code description. Any help is appreciated, thanks

Adjustment Group Codes
PI : Payor Initiated Reductions

Adjustment Reason Codes
97 : The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
 

CodingKing

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Its a section of the 835 EDI file where the payer can communicate additional information about the denial. Its not always present so that could be why you cant find it. I'm not sure what software you use and I'm not very familiar with many so if you don't know where this information populates you may wabnt to check with your EDI vendor

For example this is what Blue Cross transmits

This segment may be sent only for BlueCard remittances if the data has been returned from the Blue home plan. If present, the 1000A PER Medical Policy URL segment is also sent.
 

lmmom64

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Depends on the reason. We have been getting "diagnosis is inconsistent with the procedure"denials a lot-- I work for an ambulance company. So we are submitting retro auth appeals because insurance said they denied because the trips didn't have prior authorization AND an ICD-10 code consistent with transport.
 
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Can some one please explain what attached remark code means 16- claim service lacks information or has submission error rejection code or remittance advice remark code Loop 2210 service payment information.
 

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sls314

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Can some one please explain what attached remark code means 16- claim service lacks information or has submission error rejection code or remittance advice remark code Loop 2210 service payment information.


The 16 tells you that there's a submission error on the claim. The remark code M51 is giving you more specific information about what the submission error was - "missing/incomplete/invalid procedure code."

I see that you were billing G0151 and that the plan is UHC Dual Complete. There's something that UHC doesn't like about the code you're using and the way you're using it - were these services home health PT?

It's hard for me to say exactly why they are having an issue with the code, without seeing the full claim and knowing what services were rendered. Researching remittance remark codes can be a process with a lot of trial and error. Once you figure it out, keep notes because it will likely come up again if you bill for this service to this plan frequently!

Good luck! You may end up having to make a phone call if you can't figure it out. (I always use phone calls as a last resort, but sometimes it has to be done.)
 

louise07

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filed to Molina codes 21030 and 99152, I got the authorization on these two codes. Now they are sending on code 21030 that a modifier is required. I am confused. Any suggestions?
 
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