How to work on Medicare denial - 22, 24 & 109

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When working on these denials, it may create confusion sometimes because when you check eligibility on the Medicare portal or Medicare IVR, you find 2 options - MCO/HMO & MSP and it may be possible that the insurance is available in both tabs then it is difficult to find the correct primary insurance to bill the claim. This post will help to resolve the confusion. Please go through the complete post to have a clear understanding.

1. Denial 24 (Covered under managed care plan) & 109 (Not covered by this payer):

Scenario 1: On these denials, you need to refer to the MCO/HMO tab and the insurance available under this tab will be the primary insurance. After updating this insurance as primary, you do not need to keep the Medicare insurance as a secondary payer because the MCO/HMO plan pays on behalf of Medicare.

Scenario 2: On denial 109, there is another possibility that you will not find any insurance under the MCO/HMO tab. In that case, there may be a possibility of the patient enrolled in Railroad Medicare then you will need to submit the claim to Railroad Medicare (Palmetto Railroad) with the same policy ID.

2. Denial 22 (Other Payer Primary):

Scenario 1: On this denial, you need to refer to the MSP tab and the insurance available under this tab will be the primary insurance. Once you find the primary insurance information then update it as primary insurance and keep Medicare insurance as a secondary payer. Note: Whenever you are making Medicare as secondary, always update the MSP code. Please visit the below link to learn more about the MSP code,

https://www.arlearningonline.com/2020/01/msp-medicare-secondary-payer.html

Scenario 2: There is another possibility that you will not find any insurance under the MSP tab. In that case, you can resubmit the claim to Medicare.

Scenario 3: You may find multiple insurances in the MSP tab, in that case under each insurance name, you will find the MSP code of the insurance. This MSP code will help to identify insurance types. 

MSP Codes:
12 - Commercial insurance with health coverage for beneficiary with age 65 or above
 13 - Commercial insurance with Health coverage for End-Stage Renal Disease beneficiary
 14 - Auto Insurance
 15 - Worker Compensation
 41 - Black Lung Insurance
 43 - Commercial insurance with health coverage for beneficiary under age 65
 47 - Liability Insurance

Example - You find 2 insurances under the MSP tab with MSP code 12 (Commercial insurance) & 14 (Auto insurance). In that case, you will need to identify the service whether it is related to health coverage or Auto injury. If it is related to health coverage then you will need to make primary insurance to an insurance that has MSP code as 12 and keep Medicare as secondary with MSP code 12. In the same way, if the service is Auto related injury then you will need to make Auto insurance as primary which is mentioned with MSP code 14 and Medicare as secondary with MSP code 14.

3. Other Possible Scenarios:

Sometimes, while checking the eligibility you can find a scenario where insurance is available in both MCO/HMO & MSP tabs. In that case, identifying the correct primary and secondary insurance is a little bit tricky. The below examples will help to identify the correct primary and secondary insurance.

Example 1 - There is an insurance in the MSP tab with MSP code 43 (Commercial insurance) and another insurance is under the MCO/HMO tab.

In such a scenario, you can make the insurance as primary which is available under the MSP tab and keep the insurance on secondary position which is available under the MCO/HMO tab. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)

Example 2 - There is an insurance in the MSP tab with MSP code 15 (Worker Compensation) and another insurance is under the MCO/HMO tab.   

In such a scenario, you need to identify whether a service is related to a work-related injury or not. If it is not then you do not need to bill the claim to WC, you can directly make the MCO/HMO plan as primary insurance. Do not need to keep Medicare as secondary and submit the claim to the MCO/HMO plan.

If the service is related to work-related injury then you can make WC as primary and keep the MCO/HMO plan as secondary and submit the claim to worker comp. (No need to update the MSP code, it is needed when the original Medicare is updated as secondary)
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Interview Questions - Part I

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Tricare & VA Coverage

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TRICARE:

  • It covers active and retired military personnel and their dependents, survivors and certain former spouses.

VETERANS AFFAIRS / ADMINISTRATION (VA):

  • Veteran - Veteran is a person who has served in the army, navy or air force, especially during a war.
  • It covers the spouse or child of a veteran who died on the duty or who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.

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B20: Procedure/service was partially or fully furnished by another provider

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Denial Occurrence:
  • This denial occurs when multiple providers billed the same service on the same date of service.
  • The providers can be part of same or different Group/Facility/Hospital.

On Call Scenario:

                                         Claim denied as it is already paid to another provider
                                                                              ↓
                                                            May I get the denial date?
                                                                              ↓
                                     Check in system if the same service on the same DOS
                                     has already been billed and paid to another provider
                                                   ↙                                                    ↘
                                             Yes                                                         No
                                          ↙                                                                    ↘
                         What is the time                                    Could you please provide the name
                       frame for  to submit                                  and NPI of the provider to whom
                       the corrected claim?                                     the payment has been made?
                                     ↓                                                                           ↓
                          May I have the                                                 What is the Fax# or
                       claim# & call ref#?                                              Mailing address to
                                                                                                      send an appeal?      
                                                                                                                  ↓
                                                                                                      How much is the
                                                                                                           time limit?
                                                                                                                  ↓
                                                                                                       May I have the
                                                                                                   Claim# & Call ref#?

Important Notes & Actions:
  • Please take action as per your process update. Below actions can be different from your process update.
  • If you find the same service on the same DOS under a different provider in your system then you can submit corrected claim after appending 77 modifier.
  • If the payer is Medicare then do not need to submit corrected claim, you can append 77 modifier and resubmit the claim.
  • If you do not find the same service on the same DOS under a different provider in your system and it is part of different group then you can send an appeal to insurance.
  • Sometimes, clients wants to write off such claims. So, work as per client instructions.
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TFL & AFL Calculator

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Scenario Based Quiz - Capitation Agreement / Managed Care Plan

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1. What is Capitation?




2. If you receive the status on call as the claim is denied for denial code - 24 and the payer is Medicare or Medicaid then what will be your next valid questions?




3. If the claim is denied for denial code - 24 from Medicare payer and you are able to find the managed care information on the Medicare website but unable to find policy ID for managed care insurance and you do not have a website of managed care insurance then what will be your action?




4. If the claim is denied for denial code - 24 from non Medicare/Medicaid payer and the rep confirms that the patient is not covered under the capitation and agrees to reprocess the claim then what will be your action?




5. If the claim is denied for denial code - 24 from Medicare/Medicaid payer and you are able to find the managed care information then while billing the claim to managed care insurance, will you keep the Medicare/Medicaid payer as a secondary payer?


6. What could be the possible reasons for the claim to be denied for denial code - 24?




7. If you are working on a claim that has a DOS as 01/20/2024 and the capitation period starts from 01/01/2023 and ends on 12/01/2023 then what will be your action?




8. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid then what will be your next valid questions?




9. If the claim is denied for denial code - 24 from the Medicare/Medicaid payer and rep confirms the managed care insurance, policy ID and mailing address then what will be your action?




10. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and rep confirms that the patient is not covered under the capitation agreement then what will be your next valid questions?




11. What is Fee-For-Service (FFS)?




12. If the claim is denied for denial code - 24 from a non-Medicare/Medicaid payer and the rep confirms that the patient is covered under the capitation and the DOS lies between the capitation contract period then what will be your action?




13. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and the rep confirms that the patient is covered under the capitation agreement and the DOS does not lie between the capitation period then what will be your next valid questions?




14. If you are working on a claim that has a DOS as 01/20/2024 and the capitation period starts from 01/01/2024 and ends on 12/01/2024 then what will be your action?




15. If you receive the status on call as the claim is denied for denial code - 24 and the payer is not Medicare or Medicaid and the rep confirms that the patient is covered under the capitation agreement then what will be your next valid question?








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Scenario Based Quiz - Duplicate Service

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1. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different and the rep agrees to reprocess the claim on probing then what will be your next valid question?




2. If the claim is denied by non-Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are the same but the exam times are different then what will be your action?




3. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different but the rep denies to reprocess the claim and ask to send the corrected claim then what will be your next valid question?




4. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different then what will be your action?




5. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and modifiers on both the charges are different and the rep denies to reprocess the claim and ask to send an appeal then what will be your next valid questions?




6. If the claim is denied by non-Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different then what will be your action?




7. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the CPT is billed once only on DOS then what will be your next valid question?




8. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are the same but the exam time are different then what will be your action?




9. If the claim is denied by Medicare insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and both are exact duplicates then what will be your action?




10. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS and rendering providers on both the charges are different but the time frame to submit the corrected claim has been crossed then what will be your action?




11. What are the possible reasons for the claim to be denied as Duplicate service?




12. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS but the modifiers on both the charges are different and the rep denies to reprocess the claim and asked to send an appeal then what will be your action?




13. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the CPT is billed once only on DOS and the rep provides the original status as the claim is paid to the provider then what will be your next step?




14. If the claim is denied by the insurance for duplicate service and when you check in the system you find that the same CPT is billed more than once on DOS but the modifiers on both the charges are different but the rep denies to reprocess the claim and asked to send an appeal and the time frame to send an appeal has been crossed then what will be your action?




15. If you receive the status on call as the claim is denied for duplicate service and when you check in the system then you find that the same CPT is billed more than once on DOS and rendering providers on both charges are different then what will be your next valid question?








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