Chapter 13 Commercial Insurance Carriers

Question 1

In this chapter, commercial insurance carriers such as Aetna, UnitedHealthcare, and Cigna will be reviewed.

Answer 1

Understanding common denials from insurance companies
Explain the appeals process for Aetna, UnitedHealthcare, and Cigna

Question 2

Common Denials/Rejections

Answer 2

*Implement front office policies and procedures to reduce front end errors that cause denials and rejections

*Understand when corrected claims and appeals are warranted

*Submit effective appeals

Question 3

A rejected claim is a claim not containing the necessary information for adjudication.

Answer 3

A denied claim differs from a rejected claim.

A denied claim is one that passed through the payer’s initial claim processing but was determined not to be a covered service or procedure based on the payer’s coverage criteria.

Question 4

Rejected Claim

you can fix it

Answer 4

Denied Claim

you can appeal it

Question 5

Incorrect Patient Information

Answer 5

*misspelling

*incorrect DOB

*invalid sub #

Question 6

Eligibility Expired

Answer 6

Another common denial occurs when the patient’s coverage was not in effect on the date of service submitted for reimbursement.

Question 7

Insurance benefits should be verified before services are rendered to avoid this type of denial.

Answer 7

Eligibility verification identifies if a patient has other insurance or relies on self-pay. T

Question 8

Prior Authorization/Referral Not Received

Answer 8

A claim will also be denied if prior authorization or precertification data is missing on the claim.

Question 9

This type of denial may frequently occur with HMO patients.

Answer 9

Enrolled members may need services that require an authorization and referral from the member’s primary care provider (PCP)

Question 10

Claim Not Covered by Insurer

Answer 10

Non-covered services provided to a patient will result in a payer denial. Exclusions or non-covered services refer to certain medical services excluded from the payer’s health insurance coverage under the patient’s plan.

Question 11

Request for Medical Records Not Received

Answer 11

In some cases, a payer may request medical records to adjudicate a claim.

When records are requested by payers, the request should be completed quickly to keep the adjudication process moving forward and avoid a denial.

Question 12

EXAMPLE

ABC Health Policy: Modifier 22 - Increased Procedural Services

Answer 12

To be considered for additional reimbursement when reporting modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual service or procedure is required

Question 13

Coordination of Benefits Issues

Answer 13

Coordination of benefits (COB) is the process of determining which of two or more insurance policies will have the primary responsibility for paying a claim, and the amount that the other policies will contribute

Question 14

EXAMPLE

UnitedHealthcare provides the following tips on submitting electronic COB claims:

COB electronic specifications

For secondary professional or institutional claims to be paid electronically, the COB information must be submitted in the applicable Loops and Segments. Loops include:

Question 15

Claim Covered by Other Insurer

Answer 15

Similar to a coordination of benefits denial, this type of denial occurs when the claim is a liability case.

When a patient has had an auto or work-related accident, the commercial insurance plan will most likely deny coverage until the workers’ compensation, auto insurance, or other liability carrier has been billed.

This type of issue can be avoided with a thorough intake of the patient at the time of the visit

Question 16

Missing or Invalid CPT®, HCPCS Level II, or Diagnosis Code

Answer 16

Current coding materials (books, software, encoders, etc.) should always be used to ensure that the most current codes are assigned on a claim. A biller needs to understand when other codes are required by a payer, such as HCPCS Level II by Medicare or other carriers and Category III codes versus unlisted or other CPT® codes.

Question 17

A quality assessment of coding should be performed on a routine basis for all staff who assign codes.

Answer 17

Offer education on coding and billing so staff can keep up with the latest methodologies. If this type of denial is received, the medical record should be pulled and reviewed along with the charge entry to assess if the claim was coded and submitted correctly.

Question 18

EXAMPLE

Answer 18

This claim has procedure code 99224 reported for a 2024 date of service. In the CPT® code book, 99224 is a deleted code for 2024. The coding department should determine if the medical records support a different code.

Question 19

Timely Filing

Answer 19

Each payer has a timely filing limit that is published to make all providers aware of the time that is granted to submit a claim for payment. Some payers have a 90-day timely filing limit, some 180 days, some one year, and some are specified by individual contract

Question 20

Duplicate Claim

Answer 20

If a claim has been adjudicated and a decision made, the claim is closed by the payer. If the claim is then resubmitted by the provider, a duplicate claim denial will be sent. Keeping track of outstanding claims and timely posting of payments should decrease this type of denial.

Question 21

Medical Necessity Not Met for Service

Answer 21

*Medical necessity is defined by each payer, but when a medical necessity denial is received, it indicates the diagnosis code submitted with the procedure code does not meet coverage guidelines.

*Payers publish coverage determinations similar to Medicare’s Local Coverage Determinations, in which the payer indicates the circumstances for coverage for services and procedures.

*They indicate applicable procedure and diagnosis codes.

Question 22

Termination of Coverage

Answer 22

If services were provided to a patient after their coverage was terminated for any reason

Question 23

Bundled Service

Answer 23

If a service is billed that is bundled into another service, or falls under the global surgery package, it will be denied.

If the service is bundled, or is part of the global surgery package, it should be written off.

Question 24

This denial is also received on valid claims in some instances when modifiers are not appended to the procedure to indicate that the global surgical package or bundling issue should not apply

Answer 24

For example, a patient is under a 10-day global period for an intermediate wound repair performed on his trunk, CPT® code 12034.

On the third day, the patient presents to the office with complaints of asthma exacerbation.

A claim for an E/M service is submitted but denied due to bundling issues. When the claim is reviewed, it is determined that modifier 24 can be applied to indicate the service was unrelated to the global service.

Modifier 24 was not appended to the E/M code on the original claim submission.

Question 25

Modifier 25—Significant, Separately Identifiable Evaluation and

Answer 25

Modifier 58—Staged or Related Procedure or Service by the Same Physician

Question 26

Modifier 59—Distinct Procedural Service

Answer 26

Modifier 78—Unplanned Return to the Operating/Procedure Room by the Same Physician

Question 27

Modifier 79—Unrelated Procedure or Service by the Same Physician

Answer 27

During Post OP Period.

Question 28

Section Review 13.1

What is a rejected claim?

Answer 28

Answer: B. A claim that does not contain the necessary information for adjudication.

Wrong answer bcuz this would be denied. not rejected.
Answer A: A claim that has passed through the payer’s initial claim processing and was determined not to be a covered service based on coverage criteria.

Question 29

Which modifier is used to indicate that an E/M service is unrelated to the global service?

Answer 29

Answer: A. 24

Question 30

Which denial occurs when the claim is a liability case and was submitted to the health insurance?

Answer 30

Answer: D. Claim covered by other insurer

Rationale: Similar to a coordination of benefits denial, a claim covered by other insurer denial occurs when the claim is a liability case such as auto or work-related accident.

Question 31

Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service is which modifier?

Answer 31

Answer: B. 25

Question 32

Which of the following denials is one of the leading reasons a claim is denied and can be prevented by accurate intake information being collected every time?

Answer 32

Answer: D. Incorrect Patient Information

Question 33

Appeals

Answer 33

If a claim is denied, investigated, and found to be in error, file an appeal. Different health plans have different timelines and policies regarding their appeal processes

Question 34

Aetna Appeals Process

Answer 34

Peer to Peer Review: Aetna allows providers to submit additional information and discuss the claim with a reviewer.

Question 35

Aetna Appeals Process

Answer 35

Reconsiderations: These are formal reviews of claims reimbursements if a provider believes he or she was paid at an incorrect rate or not according to contract,

Question 36

Appeals: These are written or verbal requests that are submitted by a provider to change:

Answer 36

*adverse consideration

*adverse initial claim decision based on LOMN

*Denial for non inpatient hospital services

*adverse inital utilization review decision.

*adverse Utilization review decisions are decisions made during precertification, concurrent, or retrospective review processes for services that require precertification.

Question 37

page 157

UnitedHealthcare Appeals Process also a form.

Answer 37

UnitedHealthcare will review:

*Whether a claim was paid correctly (underpaid, paid to incorrect provider, etc.)

*Whether the provider information and/or contract are set up correctly

*A Reconsideration Request may be filed on the phone, electronically, or on paper.

Question 38

Cigna Appeals Process

Answer 38

Many claims that have been denied due to claim processing errors or missing claim information can be resolved informally by contacting Cigna HealthCare and speaking with their claim service center.

Question 39

Cigna Appeals Process

Answer 39

*Contractual disputes for resolved through single-level appeals.

*Review must be initiated within 180 calendar days from the date of the initial payment or denial decision from Cigna. Times may differ by provider agreement.

*The appeal will be performed by a reviewer not involved in the initial decision.

*The reviewer will decide based on the provider’s agreement terms and/or the patient’s benefit plan within 60 days.

*After exhausting the internal appeals process, the healthcare provider may go through arbitration.

Question 40

Cigna Appeals Process

Answer 40

*To file appeal, submit EOB

*And other documents

Question 41

Section Review 13.2

For Aetna, how long does a provider have to file a reconsideration?

Answer 41

Answer: D. 180 calendar days from the date of the initial claim decision

Question 42

According to the policy above, if a denial is received on a UnitedHealthcare claim, a reconsideration must be submitted within what timeframe of the date of the EOB or PRA?

Answer 42

Answer: A. 12 months

Rationale: A reconsideration must be submitted within 12 months of the date of the EOB or RA.

Question 43

When submitting an appeal to Cigna for timely filing, which of the following is NOT required?

Answer 43

Answer: D. The patient’s complete medical chart

Question 44

Which of the following includes provisions for the appeals process?

Answer 44

Answer: A. Patient Protection and Affordable Care Act

Question 45

If a provider wishes to submit for a single level provider payment review from Cigna, what is the timeframe for this type of dispute?

Answer 45

Answer: C. 180 days

Question 46

Bundled service—

Answer 46

A method by which the insurance company decides to combine payment for two or more medical services.