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Tricare Denials

2016-11-04T17:55:00.001-07:00

TRICARE

PayerInfo:

 Website:www.myTRICARE.com

oLoginInfo:O:\InsuranceWebsites

 PhoneNumbers:

oTricare:1‐877‐988‐9378

 Fax#1‐855‐831‐7041

oTricareforLife:1‐866‐773‐0404

 Fax#608‐301‐3100

ImportantPayerInfo:

oRuleofthumb–iftheEOBlistsapatientresponsibilitythenwecanbillthepatient.

o If theEOBdoesn’tindicatepatientresponsibility,thebalanceneedstobeadjusted.

 Tricareisalwaysthesecondarypayertoallotherinsurance,exceptIndianHealthService(IHS)

andMedicaid.

 Timelyfiling:

oClaimsubmission:1yearfromDOS.

oAppeals:90daysfromEOBdenial

 InpatientPlaceofServicedenials/issues:Pleasecallpayerandinquireif thisshouldbecovered undertheinpatientauthorization,astheprofessionalcareprovidedoccurredduringthe patient’sauthorizedinpatientstay.

oIf youseePOS21ontheHCFA,pleasereviewforanauthorizationwithinEPIC.

 Exampleofinpatientauthorization#400843605/100173818validfrom5/23–

5/25.

o If youdon’tseeanauthorizationwithinEPIC,pleaseuseanadvancedfilter tosearchfor theDX’sbilledtoseeifwe’vebeenpaidonotherclaimsduringthesamevisit.

 If sameDX’shavebeenbilledandpaid,requestforclaimtobesentbackfor review.

CommonDenials:

CO185– ThisdenialmeanstheprovidersneedtoregisterwithTricare(separatefromenrollment).To workthisdenial:

 CallTricare,andverifyiftheproviderisregisteredwiththispayer.

oIf provideris registered,requestforclaimtobereprocessed.

 If provideris notregisteredwithTricare,pleasetransfertoWQ17591forregistrationtobe completed.

CO18/N522–Duplicates– ThisdenialareforCPT’sbilledmorethanonceforthesameDOSbythesame provider.Toworkthisdenial:

 SortclaimsbyDOStoverifyhowmanytimestheCPTinquestionwasbilled,andverifyifthere areanymodifierstodistinguishseparateservice.

 Reviewtoseeifpaymentwasretractedorrefunded.

 ReviewtheEOBtofindtheoriginaldenialincaseclaimwasCC’dorretro’d.

 Checkundistributedcreditstoseeif payerpaid,andpaymentwasundistributed.Ifpayment matches,DOS,provider,CPT& Modifier,andbilledamount– distributethepayment.

 Checkmedicalrecordsto confirmwearebillingthecorrectnumberofprocedures.

o If theMedicalrecordsDONOTsupporttheextraservice,andtheclaimis trulya duplicate– pleasevoidthecharges.

o If theMedicalrecordssupportthebillingandmodifiersbilled,callthepayerandadvise themoftherepeatproceduresandhavethemreprocesstheclaim.

 If Payeradvisestheyneedmedicalrecordstosupportthebilling,askifweneed canjustsendinmedicalrecordsorifwehavetoappeal;askif thereisa requiredformthatneedstobeincludedformedicalrecordssubmissionor appeal;askifthemedicalrecordsorappealcanbefaxedorif theyhavetobe mailed(besuretonotethedetailsforeachoptionin thenotes).

MA04‐Can’tmakepaymentwithoutPrimeEOB– Thisdenialresultswhenthepayerhasn’treceived theprimaryEOB.Toworkthisdenial:

o If thereisotherinsurancelisted,checkforanEOBfromtheotherinsurance.

 If wehaveanEOBwithavaliddenial,faxcopyofEOBtoTricarewiththeclaim#

typedoutontheEOB(forpayertoeasilyreference).Fax#1‐855‐831‐7041.

 If wedon’thaveanEOBfromtheotherinsurance,calltheotherpayerand requestacopyorprintfrompayerwebsite.

^o^{If t}^h^e^other^insurance^is^f^o^undⁱⁿ^Epⁱ^c^a^nd^has^been^verified,^b^u^t^claim^has^ne^v^er^be^eⁿ

billedtotheprimaryinsurance–pleaseselectDefaultCoveragein EditVisitCoverageto billtheproperinsurance.

^o^{If t}^h^ere^{is no}^other^payerⁱⁿ^f^o^foundⁱⁿ^{Registration:}

 Callthepayertoseeiftheywillprovideustheotherpayerinfo.

 Verifythepatient’sothercoverage,andupdateregistration.

 If theaccountreactivatesandwestilldon’thavetheotherpayerinfo andit’sbeen14dayssinceasmarttextletter hasbeensent,NPR balancetoself‐pay.

CO97/M19andCO231–Thesedenialsarebundlingdenialsfromthepayer.Toworkthisdenial:

 CheckEncoderPro/CodeCorrect,andverifytheCPT’sbilledontheDOSforpossiblebundling issues.

 CallpayerandverifywhatCPTisbundledtotheprimaryCPT.

 Oncebundlingissuehasbeenconfirmed, Checked in NATIONAL CODE CORRECT,check whether it is a valid denial or invalid.If it is a valid denial,call the payor and asked them to reconsider the decision and if rep refused,appeal them with appropriate MR.

N545–PMTreducednotEprescribed.Thisdenialis seenwithinsurancecrossoverissuesfrom

Medicare.Toworkthisdenial:

 Callpayerandverifyif theyhavereceivedthecrossoverclaimfromMedicare.

oIf noclaimonfile,resubmittheclaimtoTricare.

o If theclaimis onfile,verifyiftheyhavereceivedtheprimaryEOB(crossoverclaimmay havecrossedoverwithoutone).

 Verifywiththepayerif wecanfaxthisinfo,andnotethefax#inyournotes.

 If patienthastertiaryinsurance,reviewtheprimaryandsecondaryEOB.If youTricareadvisedthey receivedtheclaimbutdeniedCO23– thismeansthepreviousinsurancepaidmorethanwhat Tricarewouldhavepaid.PleaseadjustremainingbalancewithCO23.

PR31–Deniedpatientcan’tbeidentifiedasourinsured.ThisdenialresultswhenwebillthewrongID

orpatientnameonclaim.Toworkthisdenial:

 Verifyonthewebsiteif wehavethecorrectID#,andverifyif thepatientis trulyeligible.(Please beawareTricarerequireseithertheSponsorsSSN9 digitstobebilledorwewillneedthe benefitsID#includingthedependentcode– example0061368800followedby00,01,or02).

o If youenterthedetailsonthewebsite,andnothingpullsup‐ pleasecallthepayerto verifythepatient’scoverage.

o If thepatient’sbenefitID# endsin00or01,andtheDOBisfora child,pleasetry enteringthebenefitID# witha 02‐09;thiswillmatchthepatientbytheirDOB.Once youhaveidentifiedthecorrectdependentcode,updateRegistrationwiththeproper benefitID#,andrebilltheclaim.

 If theprimaryinsurancehaspaidbeforeTricare,andVFOis usedtobillthe properinsurancetheprimarypaymentwillgoundistributed.Pleaseredistribute thepayment,andthenNRPtheclaimtobillTricarewiththecorrectID#.

^o^{If you}^have^verified^oⁿ^t^h^e^website^the^patieⁿ^t^is^e^ligible^an^d^we^hav^e^the^corr^e^ct^ID^#,

oryouhavecalledthepayerandhavealsoverifiedthisinfo– pleaseverifywhythey deniedtheclaimifwehavethecorrectinfo.Requestforthepayertoreprocessthe claim;if theclaimdeniedforanotherreason,pleaseworktheupdateddenial.

OAL6–Providerallowed/paidamountfromprimecoverage.ThisdenialisworkedsimilartotheMA04 denial.Toworkthisdenial:

 VerifyTricareinRegistrationthatthispayerislistedasthepayeroflastresort(shouldnotbe primeunlessthereisnoothercoverage).

oIf thereisa primaryinsurancelistedwithTricare,pleaseupdatethefilingordertoshow

Tricareassecondaryandbilltheproperinsurance.

o If wedon’thaveanyotherinsurancein Registration,pleasecallthepayerandverify whotheothercoverageis.If payerwillnotreleasethatinformation,pleasetransfer accounttoWQ30751fora phonecallorsmarttextlettertobesenttopatient.

 If thereisotherinsuranceonfile,andtheyhavepaid.CallTricare,andverifyif theyhavetheEOB.If theydon’t,pleasefaxtheprimeEOBtothemat855‐831‐7041forTricare.TricareforLifeplans, pleasefaxto608‐301‐3100.

o If primaryinsurancedeniedtheclaim(andis notpatientresponsibility),pleaseNRPthe claimbacktotheprimaryinsurancefortheteamtoworkthedenial.

Blanks– Theblanksarefornoresponsefromthepayer.Toworkthisdenial:

 Reviewclaimtoseeif claimhaseverbeenCC’dorretro’d,andreviewtheEOB.

 CheckRegistrationtoseeif patienthasothercoverage,becauseTricareisalwayssecondaryto allotherpayersexceptforIHS.

o If patienthasothercoverage,verifypatient’seligibilityandif patientis eligible,billthe propercoverageusingtheDefaultCoverageoptioninEditVisitCoverage.

oIf thereis nootherinsuranceonfile,followthenextbulletpoint.

 If wedon’thavearesponsefromthepayer,checktheInsuranceTimelyFilingatO:\ARTeam

andverifyifwearewithinthetimelyfilinglimit.Ifpatientiseligibleandwearewithinthetimely guidelines,callthepayerandverifyiftheyhaverecordoftheclaim.

^o^{If payer}^advi^s^es^they^D^O^N^OT^have^rec^o^rd^o^f^t^h^e^claⁱ^m,^verify^{if t}^h^ey^accept^EDI^claims.^If

EDIisaccepted,resubmittheclaim.

 If payerdoesnotallowEDIaskifwecanfaxclaimandnotethefax#inyour notesandfax.Deferclaimfor30days.

 If payeradvisedclaimsmustbemailed,transferaccounttoWQ525with detailednotes.

CO96–Non‐coveredservices.Thisdenialwillalwaysrequirea phonecalltothepayer,toverifythe truedenial.

 Askthepayerwhytheservicesweredeniedasnon‐covered?

 Askiftheprocedure/CPTisanexclusionofthepatient’sbenefits?

o Askifthepatientis responsibleforthenon‐coveredservices,iftheprocedureisan exclusionofthepatient’sbenefits.

 Adjustmentsaretakenasalastresort;weneedtoverifywhytheservicestrulydeniedbefore adjustingorNRP’ingthebalancetoself‐pay.

CO242–Servicesnotprovidedbynetwork/PCP.Thisdenialisgenerallyseenwhenthepatientreceives treatmentfromanon‐participating/non‐contractedprovider.If youseethisANSIcodeontheEOB, pleaseproceedwiththefollowing:

 ReviewtheEOBtoseeif thereisanypatentresponsibility.If thereispatientresponsibility, adjusttheremainingamountasCO45,leavingonlythepatientresponsibility.

 If thereis nopatientresponsibilitylistedontheEOB,callhepayertoinquirethedetailsregaring thedenialandifit’srelatedtoproviderenrollment.

oIf payerconfirmsthedenialisproviderenrollmentrelated,transfertoWQ17591.

N245–Incomplete/invalidplaninfofromotherinsurance.

 ReviewtheEOBtoseeif thereisanyadditionalinformationthatcanbegiven.

 Callthepayertofindoutwhatinformationisincomplete,andwhatisneededtoprocessthe claim.

 If payeradvisestheydon’thavetheprimeEOB,ortheEOBdoesn’tmatchtheinfowearegiving overthephone,pleaseaskforafaxnumberandsendthemtheupdatedEOBwithreferenceto thepatient’sID#andclaimnumber.

PR165–PMTdenied/rcv’d,referralabsentorexceeded.

 Callthepayeranderifyif thehaverecordofareferralonfile

 If payeradvisesnoreferralonfile,askthemif theyallowretroreferralsandwhoisresponsible forsendingintheinfo

o If payeradvisesretroreferralsareallowed,askthepayeriftheycanreprocesstheclaim oriftheyneedanyadditionalinfofromustoreprocesstheclaim.

 If thepayeradvisesthereisareferralonfile,askiftheclaimcanbesentbackforreprocessing.

DUPLICATE CLAIM

2016-08-03T20:01:00.003-07:00

DUPLICATE (SAME PROVIDER) – REPORTS NOT AVAILALBE

Received denial from -------- for procedure code ----- for date of service ------ stating CO18 - Duplicate. We have same procedure code ------ for same date of service which was paid by insurance (Encounter# -------). Both claims were billed by Dr. ------- and diagnosis codes are also same. No reports attached in ICS and no modifier billed.

Please code review and advice if we can rebill claim with any appropriate modifier indicating services were rendered by our provider and we should be reimbursed separately. If coding is appropriate, please share the medical records with us to appeal the claim.

CLT 5 : CODING / BILLING

DUPLICATE (SAME PROVIDER) – REPORTS AVAILABLE

Received denial from -------- for procedure code ----- for date of service ------ stating CO18 - Duplicate. We have same procedure code ------ for same date of service which was paid by insurance (Encounter# ------ ). Both claims were billed by Dr. ------- and diagnosis codes are also same. Appropriate reports attached in ICS and no modifier billed.

Please code review and advice if we can rebill claim with any appropriate modifier indicating services were rendered by our provider and we should be reimbursed separately prior to we appeal the claim since appeal should be the last resort.

DUPLICATE (DIFFERENT PROVIDER IN OUR GROUP) – REPORTS NOT AVAILALBE

Received denial from -------- for procedure code ----- for date of service ------ stating CO18 - Duplicate. We have same procedure code ------ for same date of service which was paid by insurance (Encounter# -------). However, other encounter was billed by a different provider in our group, Dr. -------. No reports attached in ICS and no modifier.

CLT 5 : CODING / BILLING

DUPLICATE (DIFFERENT PROVIDER IN OUR GROUP) – REPORTS AVAILALBE

Received denial from -------- for procedure code ----- for date of service ------ stating CO18 - Duplicate. We have same procedure code ------ for same date of service which was paid by insurance (Encounter# -------). However, other encounter was billed by a different provider in our group, Dr. -------. Appropriate reports attached in ICS and no modifier billed.

CLT 5 : CODING / BILLING

ONLY ONE CLAIM WITH US WITH NO REPORTS – BILLED BY DIFFERENT PROVIDER NOT IN OUR GROUP

Received denial from ------- insurance for procedure code ----- for date of service ------- stating CO18 - Duplicate. We do not have other service for the same date of service. Cld ------ @ -------- to verify the name of the provider who rendered the service, spoke with --------- said Dr. --------- was paid for the same date of service and rep refused to provide any other information. Ref # -------------. We do not have this provider in our group.We do not have reports attached in ICS and no modifier billed.

CLT 5 : CODING / BILLING

ONLY ONE CLAIM WITH US WITH REPORTS – BILLED BY DIFFERENT PROVIDER NOT IN OUR GROUP

Received denial from ------- insurance for procedure code ------- for date of service ------- stating CO18 - Duplicate. We do not have other service for the same date of service. Cld ------- @ -------- to verify the name of the provider who rendered the service, spoke with --------- said Dr. --------- was paid for the same date of service and rep refused to provide any other information. Ref # -------------. We do not have this provider in our group.We have appropriate reports attached to account in ICS and no modifier billed.

CLT 5 : CODING / BILLING

DEPENDENT NOT ADDED TO SUBSCRIBER’S PLAN

2016-08-03T19:56:00.001-07:00

DEPENDENT NOT ADDED TO SUBSCRIBER’S PLAN

Received denial from United Health Care stating dependent not eligible. Cld --------- @ -------- and spoke with ----------------- said patient is not added to member’s plan and suggested we have the member call insurance and have the patient added to the plan. Last letter was sent to member on ------------ .

Please advice if we can confirm with member as to whether patient was added to policy or not.

DEDUCTABLE

2016-07-30T07:16:00.004-07:00

DEDUCTIBLE & MAXIMUM BENEFITS MET –

DEDUCTIBLE – PT ONLY HAS ONE INSURANCE LISTED IN OUR SYSTEM

Cld ----- @ ------- , spoke with -------- said claim was processed on ------ and applied whole allowed amount of $----- to patient’s deductible. Inquired with rep, if this was applied to in-network / out of network deductible. Rep said this was applied to in-network deductible and deductible for the CL year is $-------. Claim# --------. Posted the deductible and transferred balance to patient.

NOTE – PLEASE TAKE HELP OF PAYMENT POSTERS OR RAJESH/SHAN/PRAKASH IF YOU DON’T KNOW HOW TO POST DEDUCTIBLE AND BILL THE PT.

IF PATIENT HAS SECONDARY INSURANCE, PLEASE REQUEST THE EOB IS IT IS MORE THAN 30 DAYS FROM PROCESSED DATE. CHECK WITH PRAVEEN / RAJ AS TO HOW TO ADDRESS THEM.

MAXIMUM BENEFITS MET – PT ONLY HAS ONE INSURANCE LISTED IN OUR SYSTEM

Cld ----- @ ------- , spoke with -------- said claim was denied on ------ stating maximum benefits met. Inquired with rep, if this was a result of dollar value or number of visits exceed per year. Rep said this was due to dollar value which is $------ / visit which is ----- visits. Claim# --------. Transferred balance to patient.

NOTE – PLEASE TAKE HELP OF PAYMENT POSTERS OR RAJESH/SHAN/PRAKASH IF YOU DON’T KNOW HOW TO BILL THE PT.

IF PATIENT HAS SECONDARY INSURANCE, PLEASE REQUEST THE EOB IS IT IS MORE THAN 30 DAYS FROM PROCESSED DATE. CHECK WITH PRAVEEN / RAJ AS TO HOW TO ADDRESS THEM.

COVERAGE TERMINATED

2016-07-30T07:12:00.002-07:00

COVERAGE TERMINATED – SINGLE INSURANCE LISTED IN SYSTEM

Cld --------- @ -------- , spoke with ------------ said claim was denied on ----------- stating patient’s policy was terminated prior to date of service. Inquired if patient has any other policy with them however found no other policy. Policy was terminated on --------. Claim# ------------. Checked patient’s demographics and found no other insurance listed.

Please verify if pt gave any other ins at time of service? If they did, please make the changes and bill the claim to the new insurance. If they did not, can we bill the pt?

THINGS TO DO –

UPDATE THE TERMINATION IN INSURANCE SCREEN

DEACTIVATE THE INSURANCE IN PATIENT’S DEMOGRAPHICS

RAISE CLT 3 : DEMO/ELIGBILITY TASK

CLOSE DM 3 : DEMO/ELIGIBILITY TASK IF AVAILABLE

CO-ORDINATION OF BENEFITS

2016-07-30T07:10:00.000-07:00

ONLY ONE INSURANCE LISTED IN SYSTEM – OTHER INSURANCE PRIMARY

Cld -------- @ --------------, spoke with ------------ said claim was denied / pended on -------- for want of COB information from patient. Inquired with rep, if they show another insurance as primary or this is a routine check from insurance. Rep said, they show another insurance as primary and was unwilling to provide the other insurance name and suggested we contact patient. Last letter was sent to patient on ------- date. Claim# ---------. Found no other insurance in system.

Please advice if patient provided any other insurance information during time of service. If yes, please update the insurance and set the claim to rebill. If not, please advice if we can transfer the balance to patient.

THINGS TO DO –

CREATE CLT 3 : DEMO / ELIGIBILITY TASK

CLOSE PS DM 3 : DEMO / ELIGIBLITY TASK IF AVAILABLE

ONLY ONE INSURANCE LISTED IN SYSTEM – ROUTINE CHECK BY INSURANCE

Cld -------- @ --------------, spoke with ------------ said claim was denied / pended on -------- for want of COB information from patient. Inquired with rep, if they show another insurance as primary or this is a routine check from insurance. Rep said, they do not see another insurance as primary as of now and this is a routine check to verify COB. Last letter was sent to patient on ------- date. Claim# ---------. Found no other insurance in system.

THINGS TO DO –

CREATE CLT 3 : DEMO / ELIGIBILITY TASK

CLOSE PS DM 3 : DEMO / ELIGIBLITY TASK IF AVAILABLE

TWO INSURANCE COMPANIES LISTED IN SYSTEM / ENCOUNTER –

Cld -------- @ --------------, spoke with ------------ said claim was denied / pended on -------- for want of COB information from patient. Inquired with rep, if they show another insurance as primary or this is a routine check from insurance. Rep said they show other payer as primary / unwilling to say if show other payer as primary. Last letter was sent to patient on ------- date. Claim# ---------. Found XXXXX is listed as secondary insurance in encounter / listed in patient’s demographics, Cld XXXX insurance, spoke with said they are secondary insurance for the payer / policy is no longer effective.

Please verify if patient confirmed COB information with both the insurance companies. If yes, please verify which is the correct primary payer. If not, would you like us to bill the patient?

THINGS TO DO –

CREATE CLT 3 : DEMO / ELIGIBILITY TASK

CLOSE PS DM 3 : DEMO / ELIGIBLITY TASK IF AVAILABLE

CLAIM PAID THROUGH EFT – ERA AVAILABLE IN GEDI

2016-07-30T07:07:00.003-07:00

Cld ---------- @ --------- , spoke with --------- said claim was paid on ------- by Electronic Transfer Number ------------. Insurance allowed $----- and paid $----- with patient’s responsibility of $-----. It was a single / bulk EFT for $-------- . Claim# ------------ . Accessed GEDI and found we have the Electronic Remittance Advice (ERA) in website. Escalated this to team lead.

CLAIM PAID THROUGH EFT – ERA NOT AVAILABLE IN GEDI

Cld ---------- @ --------- , spoke with --------- said claim was paid on ------- by Electronic Transfer Number ------------. It was a single / bulk EFT for $-------- . Claim# ------------ . Accessed GEDI and found we do not have the Electronic Remittance Advice (ERA) in website. Escalated this to team lead.

CLAIM NOT ON FILE / CLAIM NOT RECEIVED –ELECTRONIC CLAIM (PRIMARY INSURANCE)

2016-07-30T07:04:00.002-07:00

CLAIM NOT ON FILE / CLAIM NOT RECEIVED –ELECTRONIC CLAIM (PRIMARY INSURANCE)

GOOD PRACTICE WOULD BE TO CHECK GEDI WEBSITE TO CONFIRM IF CLAIM WAS ACCEPTED PRIOR TO CALL

Cld ----- @ ----- spoke with ----- said no claim on file. Patient’s policy is effective from ------- through current and filing limit is -------. Verified payer id and it is correct as listed in system ------. Rebilled the claim to insurance again.

CLAIM NOT ON FILE / CLAIM NOT RECEIVED – PAPER CLAIM (PRIMARY INSURANCE)

Cld ----- @ ----- spoke with ----- said no claim on file. Patient’s policy is effective from ------- through current and filing limit is -------. Verified claims mailing address and it is correct as listed in system -----------. Rebilled the claim to insurance again.

BUNDLED INCLUSIVE – MODIFER 59 USED

2016-07-30T06:54:00.001-07:00

BUNDLED INCLUSIVE – MODIFER 59 USED

Above scenario, procedure code 93458 was denied by insurance stating bundled however 59 modifier was used. Please see two scenarios which you might encounter –

CLAIM STILL NOT REPROCESSED BY PAYER

Received denial from --------- for procedure code ------- stating bundled/inclusive. Found procedure code ------ was billed with modifier 59 which states “Distinct procedural service and they should reimburse separately”. Insurance should have reimbursed this procedure code separately. Cld ------- @ ---------- to verify if procedure code was reviewed with modifier 59 and still denied as inclusive, spoke with ------- said procedure code ------- was denied though it was billed with 59 modifier as bundled/inclusive and suggested we rebill claim with more appropriate modifier or appeal the claim with supporting documents.

Please review coding for procedure code -------- - 59 and see if any changes can be made and rebilled. If not, please advice if we need to appeal.

CLAIM SENT FOR REVIEW / REPROCESSING -

Received denial from --------- for procedure code ------- stating bundled/inclusive. Found procedure code ------ was billed with modifier 59 which states “Distinct procedural service and they should reimburse separately”. Insurance should have reimbursed this procedure code separately. Cld ------- @ ---------- to verify if procedure code was reviewed with modifier 59 and still denied as inclusive, spoke with ------- told rep we should have been reimbursed separately. Rep said claim is being sent for review again since we have used 59 modifiers and suggested we allow ------- days for reprocessing. Reference # -----------.

BUNDLED / INCLUSIVE – MODIFIER LIST ATTACHED AT THE BOTTOM – BELOW WOULD BE SAME FOR COMMERCIALS TOO

MEDICARE DENIAL – NO MODIFIER USED

Please review coding for procedure code ------- and see if claim can be rebilled with appropriate changes. If it was billed appropriately, please wt do with balance?

EXCEPTION –

PROCEDURE CODE 36416 & 94760 CAN BE ADJUSTED US IF DENIED. NO NEED TO RAISE THIS TASK

RAISE – CLT 5 : CODING / BILLING TASK

MEDICARE DENIAL – MODIFIER USED

Received denial from ------- for procedure code ------- was denied stating CO97 - Bundled/Inclusive. Remarks - N20 Service not payable with other service rendered on the same date. Primary procedure code --------- was billed on same day and was paid by Medicare and denied procedure code was billed with modifier -----. Cld Medicare @ ------------, spoke with -------- told her denied procedure code was billed with modifier and inquired if Medicare still denied as inclusive. Rep said procedure code ------ was denied as inclusive though billed modifier ---- and suggested we either rebill with appropriate coding changes or appeal the claim with supporting documents.

Please review coding for procedure code ------- and see if claim can be rebilled with any other appropriate changes. If it was billed appropriately, please advice if we need authorize adjustment.

EXCEPTION –

PROCEDURE CODE 36416 & 94760 CAN BE ADJUSTED US IF DENIED. NO NEED TO RAISE THIS TASK

RAISE – CLT 5 : CODING / BILLING TASK

DENIAL-AUTHORIZATION

2016-07-30T06:49:00.001-07:00

AUTHORIZATION DENIAL – PLACE OF SERVICE 21 / 22 (INPATIENT / OUTPATIENT)

HOSPITAL CLAIM AVAILABLE WITH AUTHORIZATION –

Cld ----- @ -------- , spoke with -------- said claim was denied on -------- for no authorization. Found no authorization listed in system and services were related to inpatient (21) / outpatient (22). Inquired with representative if they have the hospital claim on file since it would have the authorization# and our services should be covered under hospital authorization, rep researched and stated hospital claim has the authorization and sent the claim back for reprocessing. Also, obtained the authorization# ------- / rep was unwilling to provide the authorization#. Rep suggested to allow ------ days for reprocessing, Ref# ----------. Claim# ------- .

THINGS TO DO –

CLOSE PS DM 1 – AUTH/REFERRALS TASK

HOSPITAL CLAIM AVAILABLE WITH NO AUTHORIZATION

Cld ----- @ -------- , spoke with -------- said claim was denied on -------- for no authorization. Found no authorization listed in system and services were related to inpatient (21) / outpatient (22). Inquired with representative if they have the hospital claim on file since it would have the authorization# and our services should be covered under hospital authorization, rep researched and stated they have the hospital claim however even hospital claim does not have an authorization#. Claim# ----------.

Please verify if authorization# was obtained for this date of service? If yes, please update the authorization# and rebill all the line items and type corrected claim in the narr/dunn field of the charge screen. If no, please advise what would you want us to do with the balance?

THINGS TO DO –

RAISE CLT 1 – AUTH/REFERRALS

CLOSE PS DM 1 – AUTH/REFERRALS

HOSPITAL CLAIM NOT AVAILABLE –

Cld ----- @ -------- , spoke with -------- said claim was denied on -------- for no authorization. Found no authorization listed in system and services were related to inpatient (21) / outpatient (22). Inquired with representative if they have the hospital claim on file since it would have the authorization# and our services should be covered under hospital authorization, rep researched and stated they do not have the hospital claim on file. Claim# ----------.

THINGS TO DO –

RAISE CLT 1 – AUTH/REFERRALS

CLOSE PS DM 1 – AUTH/REFERRALS

REP UNABLE TO VERIFY IF THEY HAVE HOSPITAL CLAIM OR NOT –

Cld ----- @ -------- , spoke with -------- said claim was denied on -------- for no authorization. Found no authorization listed in system and services were related to inpatient (21) / outpatient (22). Inquired with representative if they have the hospital claim on file since it would have the authorization# and our services should be covered under hospital authorization, rep was unwilling to say if they have the hospital claim or not and advised we need to obtain the authorization from hospital and rebill the claim. Claim# ----------.

THINGS TO DO –

RAISE CLT 1 – AUTH/REFERRALS

CLOSE PS DM 1 – AUTH/REFERRALS

DENIAL-ASSISTANT SURGEON – MODIFIER 80 OR AS

2016-07-30T06:39:00.001-07:00

Above scenario, surgeon’s claim was paid (3rd screen shot) and Assistant surgeon’s claim was denied as multiple physicians / assistant are not covered.

MEDICAL RECORDS AVAILABLE – (SUREGEON AND ASSISTANT SURGEON)

Received denial from --------------- stating assistant surgeon is not allowed. Found reports available for both surgeon and assistant surgeon. Appeal the claim with both the records to let insurance know that service of assistant surgeon was required.

PS PRINT TASK SHOULD BE RAISED AFTER PREPARING APPEAL

MEDICAL RECORDS NOT AVAILABLE – (SUREGEON AND ASSISTANT SURGEON)
Received denial from --------------- stating assistant surgeon is not allowed. Found no reports available to appeal the claim.
Please share the reports for us to appeal the claim.
CLT : MEDICAL RECORDS TASK

DENIAL-ACCIDENT/ILLNESS/INJURY INFORMATION REQUIRED

2016-07-30T06:33:00.000-07:00

ACCIDENT/ILLNESS/INJURY INFORMATION REQUIRED
Called ------------ @ ---------, spoke with ---------- said claim was pended / denied on ----------- for want of Accident / Injury / Illness information from patient. Last letter was sent to member on ------ and member is yet to respond. Claim# --------.

Please advice if balance can be transferred to member to have a statement generated so that member can contact insurance and update this information or if phone call can be placed from your end to member.

PS ESC 5 : CODING / BILLING

How to appeal cigna insurance denial

2016-07-30T06:02:00.000-07:00

Appeal Request

An appeal is a request to change a previous adverse decision made by CIGNA. You or your representative (including a physician on your behalf) may appeal the adverse decision related to your coverage.

Step 1: Contact CIGNA’s Customer Service Department at the toll-free number listed on the back of your ID card to review any adverse coverage determinations/payment reductions. We may be able to resolve your issue quickly outside of the formal appeal process. If a Customer Service representative cannot change the initial coverage decision, he or she will advise you of your right to request an appeal.

Step 2: Complete and mail this form and/or appeal letter along with any supporting documentation to the address identified below. Complete and accurate preparation of your appeal will help us perform a timely and thorough review. In most cases your appeal should be submitted within 180 days, but your particular benefit plan may allow a longer period.

You will receive an appeal decision in writing.

Requests for an appeal should include:

1. This completed form and/or an appeal letter requesting a review and indicating the reason(s) why you believe the adverse decision is incorrect and should be changed. If you submit a letter, please include all the information that is requested on this form.
2. A copy of the original claim and explanation of payment (EOP), explanation of benefit (EOB), or initial adverse decision letter, if applicable.
3. Any documentation supporting your appeal. For adverse decisions based upon lack of medical necessity, additional documentation may include a statement from your healthcare professional or facility describing the service or treatment and any applicable medical records.

Mail the completed Appeal Request form or appeal letter along with all supporting documentation to:

CIGNA HealthCare
National Appeals Unit
P.O. Box 5225
Scranton, PA 18505-5225

Important: This address is intended only for appeals of coverage denials. Any other requests sent to this address will be forwarded to the appropriate CIGNA location, which may result in a delay in handling your request or processing your claim.

Wake up man!!!

2014-12-25T09:03:00.000-08:00

“Oh man, Oh man, Just wake;

Just touch the fire, Endure the pain of it,

Injuries is just a pain,

You can’t claim victory in war without shedding blood,

Just wake man, let’s hunt victory,

They’ll not care you until victory,

Idol is an endurance of pain,

Our potential transcends than star,

Your attempts may fail, but don’t fail to attempt;

Don’t forget, No one is better than you,

Let’s create seed in your land and make garden,

One day, it’ll earn fruit to us and dynasties.

Humiliation and tragedy is a key to our success until we use it against our enemies,

It’s insane to claim victory without lose and blues in our life,

Approach to your dream with an unassailable spirit until you reach victory,

Be firm in your decision, never back down, and it’ll lead us to knock the door of victory.

Sleep is inevitable to us,

We must do something before our permanent sleep!!!

Oh man, Oh man, just wake it up from creepy sleep.

Let’s face against mountains, cyclones, tsunami and all obstacles.

waiting for you baby

2014-12-25T09:01:00.000-08:00

“Is it my fault or my heart fault to love u???

I just wanna be with you…

I believed all your fake promises,

You are smiling very happily,

I’m also smiling but with pain,

You should realize, sometimes I forget myself in my life but not you;

Don’t you see I’ve been dying???

Then why you are smiling baby???

Even the solider are surviving in border but I can’t,

I’ve only one heart; you know that’s only for u baby,

Then why you are smiling, when my heart is bleeding???

Is it fair my lady???

Oh my dear, now I understand, if your smiles comes by inflicting pain on me,

You can always be smile in your life but not the whole life babe;

Don’t forget I’m also a man with heart,

My love is true…as always hovering around you…always…

Waiting for you baby…

When u gonna to hold my hands???

Protest for Right to Information act in India

2014-12-25T08:47:00.001-08:00

Right to Information act is in more than seventy world countries including India. Experts accepts that the Indian constitution is the one of the best among the world countries. It was certified by the United Nation Development Plan (UNDP).

It's the second independence for the Indian people. It was a product of citizens who brought this by the non - violence method. It was a sequence of protestors from the Rajasthan people who led by the Arun Roy in 1997.It was the first attempted to brought the Right to Information act in India by the group of Rajasthan people.

In 1990, Rajasthan Government was witnessed for the corruption, especially among the rekief camp of drought hit areas. So a commission was appointed by the Mazdoor Kissan Sakthi Sangathan (MKSS) organization. It gave a report to the Rajasthan government. It proved some of the government officials and agents were all in under scam if irrigation. Commission showed that it is a right of people to give the information about the government. And it's a duty of government to share the Information to people.

Noble leaders like Aruna Roy and Sakan Singh from the MKSS movement lead the Rajasthan people to protest for the Right to Information act. MKSS organisation against the Rajasthan government with the whole India. Strikes of MKSS extended more than 60 days in whole India. "Do or Die" a principle of Mahatma Gandhiji motivated the MKSS movement. In the April of 1997, Rajasthan government accepted the proposal by the compulsion of people.

Then the MKSS extended this rule to Tamilnadu, Karnataka, Goa, Maharastra; Delhi and through out the states of India. Due to the toiling efforts of MKSS, they founded the National Campaign People for Right to Information (NCPRI). Along with various organisations like human rights joined the hands of NCPI. RTI passed to the parliment in the 2002 and it sucessfully comes as a consitution of India in 2005 in October 12 is the celebration of RTI act!

In my point of view, even though The Right to Information is implemented in the whole India, It fails to reach the main objective. Because only 8% of people have been using the Right to Information act successfully against corruption. The reason of the failure is most of the people in India unaware about the RTI. Only educated people using the RTI against the corruption. However, this Right to Information act is powerless in front of the authenticate government agency or High politician. This is also a one of the reason why the literacy people don’t want to use the RTI against everyone. Therefore we conclude, that the RTI has been facing failure against the government. In fact, it is useful to know the information of government and its plans. This is a major reasons to form the Lokpal act against corruption.

There’s always a solution to a problem!!! If one citizen of our country raise a question against government or any person, there will be a lot of probability to fail the chances of getting the answer from them. But what if the whole nation raise a question against government??? They should answer to the question isn’t??? Yeah, this is the solution of this problem. Every Indian citizen should use the RTI against corruption. Unless we should create unity, the RTI will not be effective against in this country. If we unity no one cannot deny us!!! Let’s create Unity among us!!!

GILLISOFT FILE LOCK PRO FOR WINDOWS FREE DOWNLOAD

2014-05-29T03:24:00.000-07:00

GiliSoft File Lock Pro is an upgraded version of old Gilisoft File Lock. It is a security software product that can restrict access to files folders and drivers: lock files, folders and drives; hide files folders and drives to make them completely invisible; or password protect files folders and drives. This is an efficient and reliable application that you can use to password protect or hide files, folders and drives in a fast and easy way. With this program, nobody can access or destroy your private data without password. It protects but does not encrypt the protected files and folders, so it will never have the chance to destroy your data.

DOWNLOAD LINK

Setup file for GiliSoft

Crack file for GiliSoft

Have fun and Enjoy!!!

RAZOR BOOSTER FREE DOWNLOAD

2014-05-25T02:39:00.001-07:00

Razor Booster improves the program performance. It is particularly useful for boosting the games and some hanging softwares. Razor can able to boost 2GB Program even if you have the 1GB Ram.

DOWNLOAD LINK

Click here to get Razor Booster(40 MB)

INSTRUCTIONS

You need to sign up to use the Razor Booster

AVG Tune Up Serial Keys for 2014 and Keygen

2014-05-24T13:56:00.000-07:00

SERIAL KEYS

TuneUp Utilities 2014 Serial keys by AVT:

TMACO-HRNAV-OZGB2-ADQKE-WC2K2-XCY2J

CM2Y3-UZMDJ-J4QVG-AALBE-2Y7AB-MCVVN

CMWKQ-B4ZNG-YABPT-QNRVM-XKBSX-PNISF

CMACS-XTNAV-OZGB2-ADNMR-AC4YJ-QVFVK

CMC62-BUNGF-HHRXJ-AKEOX-D6UON-AQJZH

CM36Z-CYDBB-OB4XR-QS6RN-26MJB-3ZTTP

DOWNLOAD

Click Here to get the Tune Up Keygen

DOWNLOAD FREE KASPERSKY INTERNET SECURITY PACK 2014 FULL VERSION + CRACK+SERIAL

2014-05-24T13:43:00.000-07:00

My friends, i'm here with the "Kaspersky Internet Security 2014". Even though we have many anti virus, Kaspersky is the one of the best Antivirus in the Market. It maintains the System very healthy against viruses. Kaspersky protects against Antimalware Protection,Anti phising Protection,Advanced Parent Control and Internet Connection. Inspite of it has many features than any other Antivirus, i should reveal a truth that the Kaspersky Antivirus is a Ram killer but it maintains the PC Healthy.

DOWNLOAD

Click here to get the Kaspersky Internet Security 2014

Click Here to get Crack for Kaspersky

SERIAL KEYS

J61GQ-S49SX-1CGUU-WCFZQ ( Activates for 180 days!)

QCGUH-J8FF6-33WGA-UBY62 ( Activates for 90 days!)

4GGYH-S7HEJ-QEGXT-4C88H ( Activates for 90 days!)

MINIMUM SYSTEM REQUIREMENTS

Microsoft Windows XP and Higher version of Microsoft OS.

Processor : 800 MHz or Higher.

512 MB available RAM.

Approximately 480 MB free space on your Hard-drive.

CD/DVD drive for installation of the program from CD ROM

Computer Mouse.

Internet Connection for Product Activation and Updates.

Microsoft Internet Explorer 8 or higher.

Microsoft Windows Installer 3.0 or higher.

Microsoft .Net Framework 4.

Hint: You can reinstall the Kaspersky Internet Security 2014 and reactivate after the completion of your activation days.

HAVE FUN AND ENJOY!!!

Fixed solution for Counter Strike 1.6 100% working

2014-05-24T07:23:00.000-07:00

For the Gamers, Counter Strike1.6 is a major game among the games world. It's because of that it can able to play in the Internet Server and Local Server. Though the it is best among the strategy game, It has some bugs and some problems like Freezing.

After the installation of Counterstrike 1.6, you will start the game with enthusiastically but your scroll may revolves and revolves etc...or may have face the blank screen or may have hear the music. It's because of this platform games very comfortable for the Windows XP. but not for the after the versions. One thing we should accept in window's -08. Window's -08 will always crash when we start a game released before 2010. some games are exceptional.

In order to fix the issue,Go to my computer.>Right click>Properties>System Protection>Advanced>Settings>Data Execution Prevention (DEP)> Turn on and add the CounterStrike.exe. or Half Time Launcher.

If the Problem persists, Just Disconnect the Internet and start the game and connect the Internet again. I can't guarantee that the above first option will work or not but this should work!!! Believe Me.

Fixed solution for Euro Truck Simulator 2 100% working

2014-05-24T06:38:00.000-07:00

I know after you paste the serial number still ask for serial Number??? It doesn't allow you to play like full version??? still in trial Version??? If you say 'yes' to above all questions, We have solutions for this.

It's because of after the upgradeable or installing the patch of 1.6. They change some improvements and some developments. after the installation it may ask for serial number. If u paste any serial Number illegally,it wouldn't accept it. So the solution is simple. We have to Disconnect the INTERNET connection before going to play the Euro Truck Simulator 2. Sounds like Crazy huh??? Of course it is!!! but believe me It works!!!!!!!!

Euro Truck Simulator 2 serial Key

2014-05-24T06:16:00.003-07:00

3342J-DYJF0-XEA3K-5J0YS-40UFY or

THWYR-Y553Q-71V7H-L8KLL-4KFXE

1) NVPX0-NKW6Q-HW2XN-FC4WV-S3ADT

2) 3342J-DYJFO-XEA3K-5JOYS-40UFY

3) YR9YD-9CNV4-62KZT-04J2R-PTZ45

4) HKR19-MLUDU-2KC0X-QU17Y-DP65W

5) L4MND-CMNVE-CQLU8-ARW7F-DPK21

6) 7KWDE-K9MVO-KFM10-ACJ2Q-HY9KZ

7) ZS0UQ-QDXZ6-TUZRQ-CXC6N-SL6YF

2) 5N1RY-2ZT8T-UFKS6-X27AT-M2LY2

The above Four Highlighted keys are main Euro Truck Simulator keys.

DOWNLOAD AVG ANTIVIRUS INTERNET SECURITY PACK OF 2014 IN 32 BIT AND 64 100% WORKING UNTIL 2018

2014-05-24T03:14:00.000-07:00

Hello Friends, I'm here with AVG Internet Security 2014 Build 4259. This is the latest product from the AVG to keep your Windows System healthy and run faster. As you all internet users must want any Antivirus or any Internet Security to keep your system away from the viruses, malwares, potentially harmful things like trojans and bugs. But if you think about buy a new antivirus or internet security for your windows then please don't go to buy it. Just download it from here and activate it till 2018. The best part of AVG Internet Security is that it protects you as much as possible and also speeds up your system. Usually all antivirus and Internet Security slows down your system where as AVG Internet Security 2014 is able to speeds up your system for many times to it's regular speed!

SERIAL KEYS
_________________________________________________________________________________

DOWNLOAD

_________________________________________________________________________________

32 bit setup

64 bit setup

Serial keys

INSTRUCTIONS

_________________________________________________________________________________

Download it as per your choice, i.e. x86 for 32-bit and x64 for 64-bit.
While installing, it'll ask you for the license key, just put one of these keys.
Wait for the installation finish.
After installation finish, update it and then reboot your system.
You're done. Check license Information from "Support" Tab.
You can find that your AVG Internet Security 2014 license expires on 26 Feb 2018.
Enjoy this cool stuff!

SYSTEM REQUIREMENTS

_________________________________________________________________________________

Minimum Requirements

Processor : - Intel Pentium 1.5 GHz or Faster.
Memory : - 512 MB of RAM.
Free Hard Disk Space (For Installation) : - 1000 MB

Recommended Requirements

Processor : - Intel Pentium 1.8 GHz or Faster.
Memory : - 512 MB of RAM.
Free Hard Disk Space (For Installation) : - 1550 MB

Web Browsers for Link Scanner

Internet Explorer
Mozilla Firefox
Google Chrome

Operation Systems

Windows XP ( 32-bit & 64-bit)
Windows Vista (32-bit & 64-bit)
Windows 7 (32-bit & 64-bit)
Windows 8 (32-bit & 64-bit)

If you like my posts then do like it and share it as much as possible.

USE FACEBOOK WITHOUT HAVING INTERNET ON EVERY PHONE

2014-05-24T02:55:00.000-07:00

Hello Friends, I am here with an amazing Trick. You all like to use facebook. It's nothing but I'm telling you the Trick To enjoy Facebook Without having Internet! You just have to do is enter a number from your Phone. Just Dial *325# From your phone. Don't worry about which type of phone you have. Now a menu comes in asking your Email Id. After Filling your E-mail Id of Facebook, They'll ask for your password. Fill The password and you are done. Now use Facebook Without Internet! Enjoy it!