Claims Rework Due to Maximum Benefit Reached Denial

Working a claim that has been denied due to the patient having reached the maximum benefit for the time period depends on the who the payer is and the patient's payer mix.

Medicare

If the payer is Medicare, confirm with the therapist that a KX modifier is required.

  1. Use the to open the Edit Charges window.
  2. Confirm with the therapist that a modifier is needed and add the KX modifier to the appropriate column and select Commit. The Edit Charges window closes, and you are returned to the Client Editor.
  3. Select Resubmit from the Action column. The system automatically adds a ✔ to the Bill column.
  4. Select Pass to Next Payer or Pass to Patient, as appropriate, if the patient has signed an ABN.
  5. Click Save and Close.

Single Insurance Coverage (Medicare or Private Insurance)

If the payer is covered by one primary insurance plan, you need to pass the balance to patient responsibility.

  1. Select Pass to Patient from the Action column. The system automatically adds a ✔ to the Bill column.
  2. Select Save & Close.

Multiple Payers

If the patient is covered under more than one insurance plan, bill the next payer.

  1. Select Pass to Next Payer from the Action column. The system automatically adds a ✔ to the Bill column.
  2. Select Save & Close.

This moves the claim back to the Billable category on the Claims tab and is ready to be billed to the secondary insurance.

 

 

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