By recei B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service
Common causes of code B7 are:
1. Provider certification issues: The provider may not have been credentialed, or the rendering provider is not enrolled with the group or insurance. In CMS 1500 form, the rendering provider’s NPI and name will be available in box# 24J and 30 respectively. In the CMS 1500 form, the referring provider’s name and NPI will be available in box# 17 and 17b respectively. Client should be informed and get the provider credentialed.
2.Coding issue: If the services are not accurately coded due to which there is discrepancy in the submitted claim.
3. Lack of supporting documentation: If the submitted document does not justify the number of frequency of services billed like incomplete medical records, Progress notes. So, it states that this much frequency was not needed hence denial occurs.
4. Non-covered service: If the patient’s insurance has the limitation of the coverage and benefits. This could be due to policy exclusions, limitations, or specific guidelines set by the payer.
5. When the taxonomy code is not available on the claim form. Always resubmit the claim with taxonomy code.
6. Payer guideline: Some payers have specific coverage limitations or guidelines regarding the frequency or number of services that will be reimbursed.
7. Click here to visit NPPES website
Ways to mitigate code B7 include:
1. Ensuring provider certification: Verify that the provider is certified and eligible to perform the specific procedure or service on the date of service. This can be done by regularly updating and maintaining provider credentials and certifications.
2. System is not updated: Always update the system timely so utilize technology driven solutions.
3. Review the claim carefully to determine that all the necessary information has been submitted accurately and check the details like medical records, Progress notes if the services provided are medically necessary.
4. Some services require pre-authorization so while reviewing claim form if you find that authorisation number is not updated in claim form update it before submitting so billing team should be careful.
5. Ensure coding is correctly done and follow the standard payer’s coding guidelines. Look for any coding errors or discrepancies that may have resulted in the denial.
6.Follow up with the payer on time to take action like submission of corrected claim or an appeal, initiate the necessary steps promptly.
7. Conduct internal audits: Perform regular internal audits to identify and address any issues related to provider certification or eligibility.
8. Payer guideline: Always have the updated guidelines from the payor before submitting any claim to avoid future denial as some payers have specific guidelines regarding the frequency or number of services that need to be reimbursed.