Unlike CPT and ICD-10 codes that are used across the United States, denials codes vary from insurance to insurance. The terminology used can be vague and confusing, and may not specifically say why the claim was denied. The key code at the bottom of the explanation on benefits (EOB) or remittance advice (RA) can seem like gibberish. Medicare, specifically, can be very hard to understand and, if you call, the claims representatives refer you to a website with the same verbiage as the RA. Below are some of the most common denial codes from Medicare with a description and plan of action:
OA-109: This means the patient has a Medicare Advantage Plan instead of Medicare. Most insurances-such as United HealthCare, Blue Cross Blue Shield, Harvard Pilgrim, Tufts, Aetna, etc.-offer a senior care plan. If correct, bill the claim to the correct Medicare Advantage Plan. If incorrect, the patient needs to contact Medicare and update their co-ordination of benefits to show that Medicare is indeed the primary payer.
CO-140 or PR-31: This means that the patient name and ID don't match. You'll have to re-check the spelling of the patient's first and last name, as well as their date of birth. If you have their social security number, log onto the Medicare provider website and find the MBI through the MBI look-up. Some secondary insurance websites may also provide the correct Medicare MBI so check those, too. If you are unable to verify what is incorrect, you will have to contact the patient directly.
CO-18: This means the claim is a duplicate. Check your billing software to make sure you have not billed out the same date of service twice. Check the insurance website to make sure that they have the claim listed twice and that one has already paid or is in process. If they only have one claim on file, you'll have to contact the insurance to find out why it was denied as a duplicate.
CO-22 or PR-22: This means that there may be another insurance primary. Check the patient's eligibility on the Medicare provider website. This will tell you if there is a commercial plan primary and Medicare is secondary. It will also tell you if there is a third party liability case involved, i.e. an MVA or WC. If there is a commercial insurance primary, bill the claim to the correct payer. If there is a third party involved, you'll have to get the claim number, date of injury and adjustor name from the patient then bill the third party. It is common for the third party carrier to request medical notes from the visit and the denial from the health insurance.
CO-B9: This means the patient is enrolled in a hospice. The claim needs to be rebilled with the hospice modifier- GV.
N265 and N286: These are commonly listed together and indicate a missing or invalid NPI for the referring provider. Add the referring provider name and NPI in the correct box on the claim form and rebill.
This is not a complete list, refer to your regional Medicare website for a full listing. Also, please note that Medicare does not require the original ICN and claim resubmission code when rebilling claims.
If you have any questions regarding Medicare denials, contact us today.
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