Claim Denial Codes

Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0002 Follow-up Procedure The appropriate follow-up procedure for RAD code 0002 is submit an appeal within 90 days. Billing Tips – Allied Health, Inpatient, Long Term Care, Outpatient and Vision Care • • • • • Verify recipient SSN or the number, date of birth and issue date on the BIC. Verify recipient’s eligibility with a valid Medi-Cal BIC prior to rendering service (except in an emergency). Note: Refer to the Eligibility: Recipient Identification Cards section (elig rec crd) in the Part 1 provider manual. Verify eligibility on the Point of Service (POS) Network. Check the recipient’s DOB and the issue date on the BIC. Verify the 14 digit ID number has not been transposed. RAD Code: 0006 Follow-up Procedure The appropriate follow-up procedure for RAD code 0006 is to rebill the claim or submit a CIF within six months. Billing Tips – Long Term Care • • • Verify date(s) of service on the claim. If incorrect, resubmit with correct date of service. Verify the approved date(s) of service on the TAR. If incorrect, request correction of TAR in writing from your local Medi-Cal field office. Refer to the TAR Field Office Addresses section (tar field) in the appropriate Part 2 provider manual for field office addresses RAD Code: 0008 Follow-up Procedure The appropriate follow-up procedure for RAD code 0008 is submit an appeal within 90 days. Billing Tips – Allied Health and Outpatient • • Check the provider number/National Provider Identifier (NPI). Verify with TSC that the provider has the category of service indicator to render services billed. Allied Health • Verify correct claim form is used for services. Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0010 Follow-up Procedure The appropriate follow-up procedure for RAD code 0010 is submit an appeal within 90 days. Refer to the follow-up instructions section for more information on appeals. Billing Tips – Allied Health, Inpatient, Long Term Care, Outpatient and Vision Care • • • • Check the provider number/National Provider Identifier (NPI). Verify the recipient’s 14-character ID number. Check “From – Through” dates. Check records for previous payments. If no payment is found, verify all relevant information. Example: Procedure code, modifier and rendering provider number/NPI Allied Health and Inpatient • For transplant claims, check that the correct recipient and donor documentation was included in the Reserved for Local Use field (Box 19) on the CMS-1500 or Remarks field (Box 80) on the UB-04. Refer to the Transplants section for documentation requirements. Inpatient and Long Term Care • Long Term Care providers need to change the patient’s status from “Still under care” to “Bed hold” when the patient leaves the Long Term Care facility for an Inpatient hospital stay to avoid billing for overlapping Date of service from both the Long Term Care and Inpatient hospital. 0010 is one of the most common denial for all provider types. Our claims history shows if we have 2 claims with the same provider name, recipient, Date of Service (DOS) or same services this may causing a duplicate claim. RAD Code: 0012 Follow-up Procedure The appropriate follow-up procedure for RAD code 0012 is to bill Medicare. If already done so, rebill the claim with Medicare EOMB/MRN or submit an appeal within 90 days. Billing Tips – Outpatient and Vision Care • • • • • • • Verify that Medicare has been billed. Refer to the Eligibility Medicare/Medi-Cal Crossover Claims Overview section (medicare) in the Part 1 provider manual for eligibility information and general guidelines. Verify the recipient’s 14-character ID number with a valid Medi-Cal BIC prior to rendering a service, except in an emergency. Check eligibility on the POS Network, Medi-Cal Web site or AEVS. Verify that Medicare EOMB/MRN was attached to the original claim. Attach a denial from Medicare for the DOS. If the Medicare denial is not printed on the front of the (EOMB/MRN/RA), include a description from the back of the (EOMB/MRN/RA) or the Medicare manual when billing for a denied claim. Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0021 Follow-up Procedure The appropriate follow-up procedure for RAD code 0021 is to rebill the claim. Billing Tips – Allied Health, Inpatient, Outpatient • • • • • • • Check the date of service on the claim. Verify rendering provider number/NPI on the claim. Enter the appropriate delay reason code in the box 37A of the claim. Attach substantiating documentation to justify late submittal of the claim for delay reason codes: 1, 7, 10, 11 and 15. Verify that the claim was sent to the EDS Over-One-Year Claims Unit if billing with the appropriate delay reason code. Refer to claim form submission and timeliness instructions in the appropriate Part 2 manual for billing limitations. Verify the recipient’s 14-character ID number. Note: O-O-Y-C (over one year claims) will be reviewed under these circumstances: 1. 2. 3. 4. 5. 6. Court decisions Fair Hearings Decisions County errors for determining Recipient Eligibility Medicare/OHC delays Reversal decisions on appealed TARS Other circumstances out of Providers control Delay Reason Code 10 must always be used for Over-One Year Claims. You must include a copy of Recipient’s eligibility and bill hard copy with appropriate attachments. RAD Code: 0022 Billing Tips – Long Term Care • • • • • Verify recipient’s 14-character ID number with a valid Medi-Cal BIC prior to rendering service, except in an emergency. Verify the recipient’s date of issue on the BIC. Verify that the provider number/NPI is correct. Verify the recipient’s eligibility on the POS Network. Refer to the Share of Cost (SOC) section (share) in the Part 1 provider manual for recipient liability information. Note: Remember a recipient is not eligible for benefits under the Medi-Cal program until the SOC is spent down. Refer to the Eligibility Medicare/Medi-Cal Crossover Claims Overview section (medicare) in the Part 1 provider manual for eligibility information and general guidelines. The SOC for the Long Term Care recipient was not cleared on the 25-1 claim form. Failure to identify the reason for reduction in a recipient’s SOC. o Identify the SOC for the patient, minus the non-covered services in the Explanations field. For example, “Share of Cost 300.00 (–) non-covered services 27.70 = Pat Liab/Medicare Deduct 272.30.” • • • Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0031 Follow-up Procedure The appropriate follow-up procedure for RAD code 0031 is submit an appeal within 90 days. Billing Tips – Allied Health and Vision Care • • • • Verify provider number/NPI on the claim is correct. Verify the date of service on the claim. Check the procedure code. Verify that all relevant information is correct. RAD Code: 0033 Follow-up Procedure The appropriate follow-up procedure for RAD code 0033 is submit an appeal within 90 days. Billing Tips – Inpatient • • • • • Refer to the Eligibility: Service Restrictions section of provider manual for restricted service codes and messages. Verify recipient’s 14-character ID number with a valid Medi-Cal Benefits Identification Card (BIC) prior to rendering service, except in an emergency. Verify eligibility on the POS Network. Check the recipient’s DOB and the issue date on the BIC. Remember to indicate in Box 80 that the “service is applicable to the service restriction” and document this information in the patients chart. RAD Code: 0036 Follow-up Procedure The appropriate follow-up procedure for RAD code 0036 is to rebill the claim. Billing Tips – Allied Health, Inpatient, Long Term Care, Outpatient and Vision Care • • • • Return the RTD by the date indicated at the top of the RTD. If the claim is resubmitted, disregard the denial. Verify recipient’s eligibility with a valid Medi-Cal Benefits Identification Card (BIC) prior to rendering service, except in an emergency. Verify recipient’s name, date of birth (DOB), date of issue (DOI) and all relevant information. Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0037 Follow-up Procedure The appropriate follow-up procedure for RAD code 0037 is to bill the Managed Care Plan (MCP). Billing Tips – Allied Health, Inpatient, Long Term Care, Outpatient and Vision Care • • • • • • • Verify the recipient’s eligibility. Verify the recipient’s 14-character ID number on the RAD. Check the county code. Verify the recipient’s 14-character ID number on the BIC. Refer to the MCP Code Directory in Part 1 of the provider manual for list of MCP plans, addresses, phone numbers. It’s recommended you call MCP to inquire if there are any special billing instructions prior to billing the MCP. Determine the Health Care Plan (HCP) to be billed. Bill the appropriate HCP. Vision Care • Verify the date of service on the claim. RAD Code: 0079 Follow-up Procedure The appropriate follow-up procedure for RAD code 0079 is to rebill the claim or submit a CIF within six months. Billing Tips – Long Term Care • • Verify that the number of times or days the procedure or service was authorized by the TAR fields office is the same as on a claim. If needed, request a corrected TAR from the appropriate field office in writing. RAD Code: 0093 Follow-up Procedure The appropriate follow-up procedure for RAD code 0093 is to submit a CIF within six months or submit an appeal within 90 days. Billing Tips – Inpatient • • • • • Verify recipient’s 14-character ID number with a valid Medi-Cal BIC prior to rendering service, except in an emergency. Verify recipient’s eligibility on the POS Network. Check the Emergency Verification field. If the service was an emergency the code 81 must be indicated in the condition codes field. Enter codes in numeric-alpha order from lowest to highest. Verify that a copy of the Emergency Verification Statement was attached with the claim if the service was billed as an emergency service. For a definition of “emergency” refer to OBRA and IRCA section in Part 1 provider manual. Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0116 Follow-up Procedure The appropriate follow-up procedure for RAD code 0116 is to rebill the claim or submit an appeal within 90 days. Billing Tips – Outpatient • • • • Verify the number of days or units of service on the claim. Verify the recipient’s eligibility on the POS Network. Bill with the appropriate procedure codes. If a procedure or service is payable only once per month (30 days) and you need to bill again, wait a day or two beyond the 30 days to bill again to allow our system to update. RAD Code: 0157 Follow-up Procedure The appropriate follow-up procedures for RAD code 0157 are to rebill the claim or submit an appeal within 90 days. Billing Tips – Vision Care • • • • Verify the Treatment Authorization Request (TAR) Control Number (TCN) used on the claim is correct prior to submitting the claim. Verify that the Pricing Indicator (PI) is included after the TCN. For billing guidelines, refer to the PIA Optical Laboratories (pia), Eye Appliances (eye app), Eyeglass Lenses (eyeglass lens), Eyeglass Frames (eyeglass fram), and Treatment Authorization Request (tar comp Vision Care) sections of the Part 2 Vision Care provider manual. Verify that all information on the claim matches the Adjudication response (e.g., DOS, procedure codes, modifiers, TCN, pricing indicator, etc.) RAD Code: 0186 Follow-up Procedure The appropriate follow-up procedure for RAD code 0186 is to rebill the claim or submit a CIF with six months. Billing Tips – Allied Health • • Verify the place of service is correct. Verify Medi-Service reservation was made prior to rendering service. Note: Medi-Services are used by Allied Health, Medical Services and Outpatient providers. There are seven provider types: Acupuncturists Audiologist Chiropractors Occupational Therapists • • • Podiatrists Psychologist Speech Pathologists Refer to the Code Correlation Guide following the CMS-1500 Completion (cms comp) section in the appropriate Part 2 provider manual. Refer to the Eligibility: Recipient Identification section (elig rec) of this manual for a list of providers requiring Medi-Service reservations. Use the POS Network to make a Medi-Service reservation. Claim Denial Codes • Common Denials eLearning Tutorial The provider should use the Medi-service reservation to cancel the reservation for the recipient. This will allow the recipient to receive any additional Medi-services elsewhere. RAD Code: 0243 Follow-up Procedure The appropriate follow-up procedure for RAD code 0243 is to rebill the claim or submit a CIF within six months. Billing Tips - Inpatient and Long Term Care • • • • • Verify the information on the approved TAR. Verify that the TAR Control Number (TCN) on the claim matches the approved TCN. Verify the TCN has the correct number of digits: o 9 digits for Long Term Care providers o 11 digits for all other provider types A common reason for Denial 0243 is when the Extension TAR number is entered in Box 63. If there is an extension TAR number it must be indicated in the Remarks Area on the UB-04 in Box 80. Only the original TAR number should be indicated in Box 63. Verify that there is not an alignment issue and the complete TAR Control number is legible. RAD Code: 0250 Follow-up Procedure The appropriate follow-up procedure for RAD code 0250 is submit a CIF within six months. Billing Tips – Outpatient • • • • • • Verify the information submitted supports the level of service. Verify the service provided does not exceed the allowed quantity by Medi-Cal. FQHC/RHC providers are allowed one (01) visit per Date of Service (DOS). If providers are requesting additional services on the same DOS, additional documentation must include two different diagnosis, illness, injury, etc. Check that the drug dosage does not exceed the quantity allowed by Medi-Cal. Attach all medical justification. (Attachments should be single sided on 8 ½ x 11-inch paper.) Verify the quantity billed. Verify the procedure code and modifier. RAD Code: 0314 Follow-up Procedure The appropriate follow-up procedure for RAD code 0314 is submit an appeal within 90 days. Billing Tips – Allied Health, Inpatient, Long Term Care, Outpatient and Vision Care • • • Verify recipient’s eligibility with a valid Medi-Cal BIC prior to rendering service, except in an emergency. Verify if the recipient has a Share of Cost (SOC) and is eligible for the month of service. Collect and spend down the SOC. Allied Health, Inpatient, Outpatient and Vision Care Claim Denial Codes • • • Common Denials eLearning Tutorial Pay close attention to the eligibility message. If the recipient has a SOC then the recipient is not eligible for Medi-Cal until the SOC has been paid or obligated and services should not be billed to Medi-Cal. It is important to spend down the SOC at the time of service to ensure that the recipient if needed will be able to receive services elsewhere. Some times the SOC is collected but not spent down. Vision Care • • Verify the date of service on the claim. For billing guidelines, refer to the Share of Cost (SOC): CMS-1500 section (share cms) of the Part 2 provider manual. Long Term Care • • • Long Term Care facilities must perform an eligibility verification transaction every month for each Medi-Cal recipient residing in the facility. The eligibility verification transaction shows how much SOC a recipient must pay for the month, if any. If a recipient has not spent any of the SOC in the month, the facility bills the recipient for the entire SOC. If the eligibility message indicates a recipient has a Long Term Care SOC, the SOC should not be cleared online. Long Term Care SOC is cleared solely by the facility in which the recipient resides. RAD Code: 0341 Follow-up Procedure The appropriate follow-up procedure for RAD code 0341 is to rebill the claim or submit a CIF within six months. Billing Tips – Inpatient • • • Verify that the units requested and approved on the TAR are correct. If incorrect, request a corrected TAR in writing from the TAR field office. Verify that there are sufficient units of service approved on the TAR to cover the units billed on the claim form. Resubmit with corrected TAR. RAD Code: 0351 Follow-up Procedure The appropriate follow-up procedures for RAD code 0351 are to rebill the claim or submit an appeal within 90 days. Billing Tips – Vision Care • • • Verify that the number of days or units for the services billed on the claim do not exceed the acceptable maximum. For interim eye examinations within the 24-month coverage period, refer to the Professional Services: Diagnosis Codes section (pro serv cd) in the Vision Care provider manual for a list of valid diagnosis codes that must be billed with CPT-4 codes 92004 and 92014 for payment. Provider must justify the exam by billing the correct diagnosis codes Claim Denial Codes Common Denials eLearning Tutorial RAD Code: 0362 Follow-up Procedure The appropriate follow-up procedure for RAD code 0362 is to rebill the claim or submit an appeal within 90 days. Billing Tips – Vision Care • • • Verify that the procedure code billed on the claim is correct. Verify that the procedure code entered on the claim is valid and authorized by Medi-Cal. For billing guidelines, refer to the Maximum Reimbursement for Eye Appliance (rates max eye app) and Maximum Reimbursement for Optometry Services (rates max optom) sections of the Part 2 Vision Care provider manual. RAD Code: 0691 Follow-up Procedure The appropriate follow-up procedure for RAD code 0691 is to rebill the claim or submit a CIF with six months. Billing Tips – Allied Health and Long Term Care • • • Verify the diagnosis code used on the claim. Note: Remember to verify the diagnosis code prior to submitting the claim. Remember to read monthly bulletins for any updates/changes/deletions for diagnosis codes. Use the “highest level” of description for the diagnosis.