Resolving Denials in the Corrections Queue
This feature must be activated for your database by Clinicient. If you have questions about whether this functionality has been enabled for your practice, please reach out to Clinicient support.
Claims that have been denied for reasons relating to authorization and coverage are automatically moved to Not Ready status. When this happens, a message will appear in the Corrections Queue notifying you that the claim has been denied and explaining the reason why.
After the necessary information has been corrected:
- The claim will either automatically move to Billable status, or will remain at Not Ready status.
- If the claim stays at Not Ready, a system-generated task assigned to the Billing Role will be created prompting the billing team to resubmit the corrected claims.
- For Total INSIGHT users, Clinicient's billing team will take the final steps to resubmit claims and complete the task.
If you think the claim was denied in error, please see the section below on Troubleshooting Claims Denied in Error.
Note: After the denial EOB is posted, there will typically be a 10 minute delay before the claim updates to Not Ready status and a message appears in the Corrections Queue. If you do not see a Corrections Queue message regarding a denial for one of the reason codes listed below, wait a few minutes and then click the Refresh button in your Tasks tab in INSIGHT EMR.
Expand the denial reason codes in the list below for an explanation of why the claim was denied, what information must be corrected, and next steps to be taken after corrections are made.
Denial Code 20: This injury/illness is covered by the liability carrier
Meaning
Claims must be submitted to the patient's liability carrier.
Action Required
Contact the patient to obtain insurance information for the liability carrier, and update the patient's account.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When corrections have been made to the patient's insurance information, claims will go to Not Ready status and a task will be assigned to the billing team to resubmit claims with the corrected information.
Denial Code 22: This care may be covered by another payer per coordination of benefits.
Meaning
Charges are the responsibility of the patient's other insurance carrier, or the patient must update coordination of benefits with their insurance.
Action Required
Contact the patient to obtain their other insurance information or request that they update COB with the payer on file. If the patient must update COB, charges can be passed to patient responsibility and resubmitted after the patient contacts the payer.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When corrections have been made to the patient's insurance information, claims will go to Not Ready status and a task will be assigned to the billing team to resubmit claims with the corrected information.
Denial Code 24: Charges are covered under a capitation agreement/managed care plan.
Meaning
Charges are covered under a capitation plan, and claims must be sent to the correct location. This message applies only to patients who have Medicare or Medicaid Replacement plans, or another HMO-type plan.
Action Required
Review the patient's insurance card to verify the correct address or Payer EDI number where claims should be sent. If the address or Payer EDI number on the patient's insurance card matches the information on file, contact the patient to see if their insurance has changed.
Note: Rather than changing the address or Payer EDI number for the payer on file, the best practice is to create a new payer profile for the capitation or managed care plan.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's insurance information has been updated, claims will go to Not Ready status and a task will be assigned to the billing team to resubmit claims with the corrected information.
Denial Code 27: Expenses incurred after coverage terminated.
Meaning
The patient's insurance is no longer in effect.
Action Required
Verify that the insurance information on file exactly matches the patient's insurance card, and that the payer address or Payer EDI number is correct. If all information on file matches the patient's insurance card, contact the patient to see if they have updated their insurance policy.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's insurance information has been updated, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code 32: Our records indicate the patient is not an eligible dependent.
Meaning
The patient is not covered under the subscriber's plan.
Action Required
Verify that the insurance information on file exactly matches the patient's insurance card, and that the subscriber and patient relationship to subscriber are correct. If all information on file matches the patient's insurance card, contact the patient to see if they have other coverage.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's insurance information has been updated, claims will go to Not Ready status and a task will be assigned to the billing team to resubmit claims with the corrected informaton.
Denial Code 109: Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Meaning
This message applies only to Medicare Part A and B claims. Claims must be submitted to the patient's Medicare Replacement plan.
Action Required
Contact the patient to obtain insurance information for the Medicare Replacement plan.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's insurance information has been updated, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code 140: Patient/insured health identification number and name do not match.
Meaning
This message applies only to Medicare Part A and B claims. The patient name and/or member ID on file do not match the payer's records.
Action Required
Verify that the patient's name, date of birth, and insurance information on file exactly match what is shown on the insurance card, and that the payer address or Payer EDI number is correct.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The patient's name is corrected.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's name or insurance information has been updated, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code 183: The referring provider is not eligible to refer the service billed.
Meaning
The name or NPI number on file for the referring provider is incorrect, or the referring provider is not eligible to refer services for the patient.
Action Required
Verify that the name and NPI number on file for the referring provider are correct.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The referring provider's name or NPI number is corrected.
- The referral source is updated.
Next Steps
When the name or NPI number for the referring provider has been corrected, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code 200: Expenses incurred during lapse in coverage.
Meaning
The patient did not have active coverage during the time of service.
Action Required
Verify that the insurance information on file exactly matches the patient's insurance card, and that the payer address or Payer EDI number is correct. If all information on file matches the patient's insurance card, contact the patient to see if they have updated their insurance policy.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's name or insurance information has been updated claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code MA27: Missing/incomplete/invalid entitlement number or name shown on the claim.
Meaning
The payer is unable to identify the patient.
Action Required
Verify that the patient's name and insurance information on file exactly matches the insurance card, and that the payer address or Payer EDI number is correct. If all information on file matches the patient's insurance card, contact the patient to see if they have canceled or updated their insurance policy.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The claim is passed to a different Payer Index.
- The patient's name is corrected.
- A new insurance plan is added to the patient's account.
- Subscriber, member, claim, group, or policy ID numbers are updated.
Next Steps
When the patient's name or insurance information has been updated, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code MA36: Missing/incomplete/invalid patient name.
Meaning
The patient's name in Insight does not match the payer's records.
Action Required
Verify that the patient's name and insurance information on file exactly matches the insurance card, and that the payer address or Payer EDI number is correct. If all information on file matches the patient's insurance card, contact the patient to see if they have updated their insurance policy.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The patient's name is corrected.
Next Steps
When the patient's name has been updated, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Denial Code N285: Missing/Incomplete/Invalid referring provider name.
Meaning
The name or NPI number on file for the referring provider is missing or incorrect, or the referring provider is not eligible to refer services for the patient.
Action Required
Verify that the name and NPI number on file for the referring provider are correct.
Claims will leave the Corrections Queue when changes are made to one of the following:
- The referring provider's name or NPI number is corrected.
- The referral source is updated.
Next Steps
When the information on file for the referring provider has been corrected, claims will automatically move to Billable status to be billed to the payer in the next billing cycle.
Troubleshooting Claims Denied in Error
Note: This sections applies only to Total INSIGHT customers.
If you are unable to move a claim from the Corrections Queue and believe the payer denied the claim in error, please follow the steps below.
- Create a new task.
- Type Corrections Queue Resolution as the Action heading.
- Assign the task to the Billing role.
- Select the patient's name using the Client drop-down menu.
- Select the case using the Case drop-down menu.
- In the Claims section, check the box for the denied date of service.
- In the Note section, please answer the following questions:
- Why was the claim denied?
- What steps have you taken to resolve the issue?
- In attempting to resolve the issue, did you call the payer? If so, please include the name of the representative you spoke with and the reference number for the call.
- Is the payer reprocessing the claim? If not, does the claim need to be resubmitted?
- Click OK to send the task to Clinicient's billing team.
When Clinicient's billing team receives the task, they will take the appropriate action to move the claim out of the Corrections Queue.
Note: If the task doesn't initially include all of the information needed to resolve the issue, the billing team may assign it back to you requesting clarification.
