Wiki Professional Component claim denial

[santilata.achari@cardiologypartnerspl.com]

Professional Component claims are getting bundled with Technical claims, I am using modifier 26 to separate from Technical claim
still they insurance denying(Humana & Wellcare)
Is there any other modifier need to use?

 

[sls314]

Professional Component claims are getting bundled with Technical claims, I am using modifier 26 to separate from Technical claim
still they insurance denying(Humana & Wellcare)
Is there any other modifier need to use?

What denial remark code are you receiving on your physician/professional claim?

You bill the professional component under the physician on the CMS-1500 claim form.

You bill the technical component under the facility on the UB-04 claim form.

Each entity should get paid accordingly.

 

[santilata.achari@cardiologypartnerspl.com]

The Denial code & reason:

97​

:​

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

 

[sls314]

The Denial code & reason:

97​

:​

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

What other codes are on the claim with the professional component? Could it be bundling with something else?

 

[cgaston]

My guess is that whoever is billing for the technical component did not use a modifier, so they were paid the global fee.

 

[sls314]

My guess is that whoever is billing for the technical component did not use a modifier, so they were paid the global fee.

That's a very good point. If that's the case, whoever billed the technical component will need to correct their claim with the TC modifier.