This care may be covered by another payer per coordination of benefits
You might come across this denial scenario where you will get the denial from insurance as (PR-22 or CO-22).
Let me give you the answer quickly. But before you should know how it works!
The above image clearly gives you the outline of the denial workflow.
Let us consider an example.
Example
| Mark undergoes medical treatment. He has medicare as primary who is responsible for the treatment. Now by mistake instead of billing medicare (responsible payor) claim was filed to secondary (BCBS). After billing them Blue cross blue shield denies the claim with denial code CO-22. |
Do you think the above billing flow is correct? No, not at all.
Here is the reason why- Patient may hold multiple insurance primary, secondary, tertiary, and so on.
If the claim is billed to the incorrect payer who is not at all responsible for the service. It will get denied for sure.
To get more clarity about this denial you have to learn the Importance of COB- Coordination of benefits. so Let’s dive into the topic.
What is COB in Medical Billing?
As we already discussed this topic. Let us see the key points alone here, Cob is nothing if a patient has much insurance and goes to a treatment primary insurance is the first one to pay followed by secondary and tertiary.
Now the work of Cob is to determine the order of insurance who is the responsible primary insurance, secondary respectively according to the patient’s plan.
According to Mark’s case, the order of the insurance was billed incorrectly. This could happen when the patient misses updating the Cob in a timely manner. However, you can call the patient directly to update the coordination of benefits to avoid the non-sequential insurance format.
(Role of Co-ordination of benefits) in transferring a balance from one insurance to others
There are always three main divisions that provide should be aware of while filing an initial claim as follows:
- Medicare traditional.
- Workers comp or the employer group.
- Medicare advantage.
like mentioned above it is always mandatory to bill the primary insurance. when the claim is processed correctly primary insurance will pay and leave the balance to secondary.
Now secondary receive the Explanation of benefit from primary and checks the balance and it will pay.
If fortunately, the patient has a tertiary plan then the balance of secondary will go to tertiary insurance.
Due to this sequential payment patients will reduce theirs out-of-pocket money such as Deductible, Copay, Coinsurance.
Recommended steps to fix the CO 22 denial code and get paid
- Check and bill the Correct responsible payor according to the patient’s Cob.
- Update the Explanation of benefit from one payor to another in order.
- Contact patient to update the coordination of benefits.
- Need to validate if the patient has any new updated policy, if so ask them to add in COB.
- Check if it is a work-related injury and bill the correct workers’ compensation carrier.
- Need to obtain correct information from the patient on screening.
- Follow the MSP guideline on proper claim submission.
- Verify the Patient’s Medicare card and make a copy for future reference.
References and cms procedures to eliminate the denial
- Check the medicare secondary payer manual for CMS IOM Publication 100-05 for MSP information.
