By recei - Provider is out of network: If patient visited the doctor or provider as out of network that is when a provider is not credentialed with a specific insurance plan.
- Non reimbursable DX or CPT Code: Billed DX (ICD-11) or CPT code not reimbursable under patient policy. Some examples are the most frequent visit for non-covered services like therapy or services with specific diagnosis.
Denial Reason: Non-covered charges as per provider contract:
Out-of-network provider: The healthcare provider is not credentialed with the patient’s insurance network,
- If the CPT code is non-covered under the provider contract. Please check previous history; if payment was received for the same CPT billed under the same NPI from the same insurance, then the claim can be sent back for reprocessing. Non-covered service denials occur very often when a provider does not get authorization for a service.
- Coding related denial: Coding team can be contacted if non-covered denials occurred due to Dx or Cpt related issues as coding team can use alternate Dx code that can be submitted again once corrected..
- Eligibility related: If denial is related to eligibility, please work accordingly. So before providing any services, it is essential to verify the patient’s insurance coverage. Always ensure that the patient’s insurance information is updated accurately because it is the most common reason for this denial.
- Provider is out of network: If the claim is denied as the provider is out of network, then work as per SOP or process update, it can be resolved.
- Proper use of resources: Please use all the resources like websites, documents listed under PMS, and other related visits.
- Appeals: Appeals can be submitted to the payor if the claim denied incorrectly, so it is mandatory to obtain the correct fax number or appeal address.
- Fax number: Always take the fax number or appeal address to send the appeal.
Important note:
NCPDP Rejection : If the Remark Code refers to the NCPDP Reject Reason Code, refer this code in the claim documentation and work accordingly.
CO-96 denial always comes with a remark code, so read it first, then move ahead with the required follow-up.
Some examples of remark codes are listed below:
N31: Missing/incomplete/invalid prescribing provider identifier.
N30: Patient ineligible for this service. N19: Procedure code incidental to primary procedure.
M79: Missing/incomplete/invalid charge. M60: Missing Certificate of Medical Necessity.
Claim Adjustment Reason Code (CARC): These codes provide additional explanation for an adjustment.
Remittance Advice Remark Codes (RARCs): These codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC).
Also read: Underpayment