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Denial/Rejection Protocols

  1. #1
    Default Denial/Rejection Protocols
    Medical Coding Books
    Does anyone have a protocol list for how to work types of denials for new insurance follow up reps? I once saw some kind of flip book with different denial/rejection types, and when you flipped to the one you were working it guided you through what steps to take to resolve the issue.

    Does anyone have anything or know where I can get this?


    Thanks

  2. #2
    Default
    Quote Originally Posted by jesfriday View Post
    Does anyone have a protocol list for how to work types of denials for new insurance follow up reps? I once saw some kind of flip book with different denial/rejection types, and when you flipped to the one you were working it guided you through what steps to take to resolve the issue.

    Does anyone have anything or know where I can get this?


    Thanks
    1. Read the EOB.
    2. Understand the denial reason - was it a coding issue, or a coverage issue?
    3. Get specific info on what coverage/billing guideline is being referenced, and how it can be resolved.
    4. Contact the patient when necessary, and give them a specific time period to take care of things that they need to before billing them.
    5. Submit a corrected claim, when applicable.

    In order to correct a denial, it's critical that they understand it. It sounds simple, but figuring out where exactly something went wrong on a claim is harder than it seems. They can't be afraid to call the insurer and ask questions, and they need to learn how to tell when the answer they're getting is incorrect.

    Common coding denials:
    Incorrect CPT code/Modifier combination
    Invalid ICD-9/CPT/HCPCS for the DOS, patient's gender or age
    Bundling issues (E/M needs a -25 mod, labs/procedures need a -59 mod, etc.)
    Incorrect # of units billed

    Billing/Claim format denials:
    Patient's relationship code to subscriber incorrect (self, parent, child, etc.)
    Patient's info entered incorrectly (Name, DOB, policy #, group #)
    Subscriber's SSN missing/wrong
    Accident/Auto/Work Injury field is filled out incorrectly
    Onset dates (boxes 14/15 on CMS-1500) not completed
    Provider info not billed correctly or Provider not contracted with network
    Billed the wrong insurance as primary
    Didn't submit the primary EOB to secondary

    Insurer-specific:
    Service doesn't meet coverage guidelines/billing criteria

    Patient-specific denials:
    Policy not effective on DOS
    Patient doesn't have benefits for the service [ever/for the Dx indicated]
    Service is subject to a rider/pre-existing exclusion
    Patient needs to give info to the insurer (Coordination of Benefits, Accident details, divorce decree, etc.)
    Patient need to give you COB info, so you can file to the correct payer.

    That's certainly not all of the reasons things deny, but it covers most. Hope that helps!

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