Denial for COB related - How to avoid.

Denial Messages:

CO-22 or PR-22: This care may be covered by another payer per coordination of benefits.

CO 19: Claim not covered by this payer/contractor. You must send the claims to the correct payer/contractor:
  

MSP claims were denied for one or more of the following reasons:

• Secondary payment cannot be considered without the identity of, or payment information from, the primary payer. The information was either not reported or was illegible.

• The patient¡¦s care should be covered by another payer per coordination of benefits.

• Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.

• Claim denied because this is a work-related injury and, thus, the liability of the workers¡¦ compensation carrier.

• Claim denied because this injury/illness is the liability of the no-fault carrier.

• Payment is adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.

Suggestions to reduce or eliminate these kinds of claim denials:

Providers must know beforehand where to file the initial claim:

o Traditional Medicare?

o An employer insurance plan?

o MA plan?

• Patient screening is an excellent way for providers to obtain valuable information necessary for proper claims submission. Claim rejections and/or denials will occur if complete patient insurance information is not obtained or kept up to date. Providers are required to file claims based on information obtained from the patient prior to submitting the claim.

• Verify the patient¡¦s Medicare card and other insurance cards and retain a copy for your files.

• Verify and reverify the patient¡¦s eligibility information often to ensure the office information is up to date and accurate.

• The Patient Registration and Screening Guide will provide ways to implement a process or improve existing patient screening processes within the office.

Coordination of Benefits and Patient’s Share

 

Members occasionally have two or more benefit policies. When they do, the insurance carriers take this into consideration and this is known as Coordination of Benefits.

This article is meant to assist physicians, professional providers, facility and ancillary providers in understanding the coordination of benefits clause from the contracting perspective.

The information contained in this article applies to member's health benefit policies issued by Blue Cross and Blue Shield of Texas (BCBSTX). Please note: some Administrative Services Only (self- funded) groups may elect not to follow the general Coordination of Benefit rules of BCBSTX.

When the member's health benefit policy is issued by another Blues plan, also known as the HOME plan, the Coordination of Benefit provision is administered by that HOME plan, not BCBSTX. Therefore, the member's HOME plan health benefit policy will control how Coordination of Benefits is applied for that member