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DenialsProblemsFinal

 

HNS custom edits reduce denials!

 

 

To assist you with reducing the number of claims that are denied by the insurance companies, HNS utilizes a series of custom edits to help identify certain errors and/or "problem" claims that if sent to the payors, would likely result in the denial of payment for those claims.

 

 

There are two ways in which HNS receives claims; electronically and via the CMS 1500 form. When errors are found, HNS will contact you in one of two ways to let you know.

 

 

    1. If errors are found on claims submitted electronically via HNSConnect®, those claims will be rejected.  The system will notify you by listing the claim(s) as an "ERROR" and informing you of the specific problem with each claim so you can quickly correct the claim and resubmit it.

                  NOTE:  Claims with errors will NOT be submitted to the
                  payor until all errors have been corrected.

      Because it takes up to 24 hours for our systems to check your claims and identify any claims with errors, you must check the status of your claims on HNSConnect® 24 hours after you have submitted the claims, so you can correct your errors and the claims can then be transmitted to the payor(s) for adjudication.

    2. If you submit paper claims to HNS via the CMS 1500 form, these are also checked for certain problems that could cause the claim to deny and such claims will be returned to you with a HNS Claim Return Form.

      When you receive a HNS Claim Return Form or Error Form from HNS, it will be marked with the specific problem(s) with the claim. Please follow the instructions included on the form.
       

 

If you have questions about why a claim rejected on HNSConnect® or why a paper claim was returned to you with the HNS Claim Return Form, please contact your HNS Service Representative for assistance.

 

The following lists contain the most common reasons why your claims may encounter denials or problems during adjudication.

 

 

The most common reasons why claims are denied/rejected by the payor(s): 

      1. Incorrect or incomplete subscriber ID number

      2. The date of birth on the claim does not match the member's date of birth on file with payor

      3. Member not covered on the date of service

      4. Service provided is not a covered benefit under the member's plan

      5. Claims were submitted directly to the insurance company, rather than to HNS

 

 

The most common problems with a claim during adjudication:

      1. The claim has been previously submitted for adjudication (i.e.; duplicate claim)

      2. "Split" claim - the services rendered on one date of service are divided between two or more claims. (i.e; the manipulation printed on one claim, and the therapies printed on a different claim.)

      3. Incorrect group number was placed in box 11.

      4. Date of Onset (box 14) was not included on the claim.

      5. Incorrect or missing modifiers.  

 

How to avoid these denials:  

  

1.  Incorrect Member ID Number 

 

Submitting claims with an incorrect or incomplete member identification number in box 1A on the CMS 1500 claim form is the number ONE reason that insurance companies/payors deny your claims. There can be several reasons for denials associated with a member's ID number such as: 

  • Failing to include any suffix (such as "01") that appears on a members ID card 

  • Incorrectly entering the member's ID in your computer

  • Transposing numbers when completing box 1a

  • Failing to include all alpha prefixes

  • Member presents with an invalid insurance card.

 

To reduce denials, always obtain a current copy of the member's ID card at each visit and be sure that you update your practice management software with the correct information BEFORE transmitting the claim to HNS.

 

When verifying benefits, always verify the complete name and subscriber ID number, as well as dates of coverage and covered benefits.  Verify that the member ID number in your software system is exactly the same as the number on the insurance card, including all alpha prefixes and any suffixes, if applicable. 

 

Insurance plans renew and change throughout the year, not just in January! 

 

By obtaining a copy of the card at each visit, then verifying the ID number your computer matches the number on the card, you can significantly reduce your denials. 

 

If you receive a denial associated with an incorrect member ID number or other incorrect insurance information, first check the ID number on your copy of the member's ID card against the number in your computer. If you are unable to determine the cause of the problem or if you are unsure about the correct ID number, contact the member and ask them to provide you with a copy of their most current insurance card. Once you receive this card, contact the payor and verify the ID number and coverage dates.

 

2.  Incorrect Date of Birth on the Claim

 

It is very important to check ALL information on a claim prior to submitting the claim. When the payor cannot recognize the patient, the payor cannot properly adjudicate the claim.

 

Often the insurance company cannot identify the patient because the patient ID number does not match the patient date of birth. This error occurs most often with patients who have other family members (dependents) enrolled under the same plan.

 

When payors are reviewing a claim, the subscriber ID number is the first area that is checked.  Some payors have specific ID numbers for different family members and others use the same ID number. However, in either case, the payor will confirm the patient information against the patient date of birth in box 3 on the CMS 1500 claim form to confirm the patient listed on the claim has coverage for the date of service submitted.

 

To avoid these denials, always: 

  • Verify the patient date of birth with the payor

  • Correctly input the date of birth into your computer prior to submitting claims. 

 

3.  Member has no Coverage on Date of Service

 

Many denials result from claims submitted for members who have no coverage on the date of service. Such denials can be avoided by properly verifying effective dates of coverage.

 

Insurance plans renew and change throughout the year, not just in January! 

 

A patient's employment status can change or their insurance plan may change with their current employer. The patient may not remember to tell you of any changes, so it is very important to ask if any changes have occurred and make a copy of their insurance card on EACH visit.  

 

You can reduce the number of these denials by the following actions: 

  • Obtain a current insurance ID card on every visit

  • Check effective dates of coverage for each member

  • Update your computer system with current insurance information 

 

4.  Non-covered services

 

It is imperative that you always verify benefits prior to rendering chiropractic services. It is also imperative to verify each service is covered when provided by a chiropractor.

 

You can reduce the number of these denials by the following actions: 

  • Obtain a current insurance ID card on every visit.

  • Verify that each service you intend to provide is a covered service and is covered when provided by a chiropractor.

  • Use the HNS Verification of Eligibility/Benefits Form or a similar one you have created.

  • If a service is non-covered, do not bill the insurance company.  This service is NON-COVERED.

  • If a service is non-covered, have the patient sign a waiver agreeing to pay for the non-covered service, PRIOR to performing the service. Use the Non-Covered Services Waiver form or a similar one you have created.

  • Always maintain the signed waiver in the patient's healthcare record.

 

Please remember that the information you receive when verifying benefits is subject to payor corporate medical policies for chiropractic. A payor representative may tell you that the service is a covered service and then the service will deny based on corporate medical policy.

 

While most providers routinely verify chiropractic benefits, many providers fail to get sepcific benefit information for each member and/or do not realize that information provided by phone representatives is subject to corporate medical policy, which can result in a denial for services rendered that are non-covered services.

 

Once you determine that chiropractic services are covered, ALWAYS ask if there are ANY restrictions regarding: 

  • The number of visits/manipulations per year

  • Number of therapies per visit

  • Frequency of radiographs

  • Bundling of manipulation with other codes

  • Any other restrictions to the plan

  • Pre-existing conditions

  

When verifying eligibility/benefits, we also recommend: 

  • Obtain both the first and last name of the person providing you with the information

  • Document the date and time of the call

  • Always request a reference number for your call!  This can be a number or the name and date, but most payors will supply one when asked.

  • Be sure to document all information on your benefit verification checklist.

 

NOTE:  Having this documented will be helpful should a dispute arise regarding a covered/non-covered service.

 


Anytime you receive an EOB or NOP showing a denial code that you believe to be an error, please remember these services are either paid or denied by the insurance company or payor, not by HNS. HNS does not make decisions regarding the payment or denial of claims. 

 

EOB'S/NOP'S included with your HNS remittance are sent to HNS from the insurance companies or payors and we pass them on to you.  To assist with understanding the action taken by the insurance companies or payors, a description/explanation of the denial code is always included with the EOB/NOP.  

 

Please contact your HNS Service Representative for assistance in understanding why a particular claim or service was denied.  We are here to help! 

  

5.  Sending HNS claims DIRECTLY to the insurance payor
      rather than to HNS

 

Improperly submitting your HNS claims directly to the insurance companies or payors, rather than to HNS, is a primary reason insurance companies deny your HNS claims. 

 

In addition to negatively impacting your collections, improperly submitting claims directly to the insurance company or payor causes significant problems for our managed care partners and repeated improper submission of claims can jeopardize your continued participation in our network.

 

NOTE:  Please make sure all staff members and/or billing companies understand the importance of sending your HNS claims directly to HNS.

 

You can reduce the number of these denials by the following actions: 

  • Post a list of HNS contracts in various places throughout your office for easy reference for all staff members.

  • Require all staff members to learn which contracts must be sent to HNS.

  • Make sure the HNS address, not the address of the insurance company, is in your computer, for each HNS contract, to assure the HNS address always prints on the top right hand corner of the CMS 1500 claim form. 

 

Using window envelopes will assure that your claims are sent to HNS.  If you are MANUALLY addressing your claim envelopes, please make certain you address the envelope using the HNS address below, rather than the address of the insurance company.

 

                                   HNS
                                   PO Box 2368
                                   Cornelius, NC 28031

 

Ignore any instructions regarding where to send claims by payor phone representatives.  HNS instructions regarding where to send claims supersede all other instructions given by payor representatives when verifying eligibility and benefits.

  

If you are uncertain where to send a claim, email your HNS Service Representative and include a legible copy of the front and back of the member's insurance card and he/she will gladly assist you! 

 

Please be aware that for certain insurance companies, reprocessing a previously submitted claim is often a lengthy and difficult process.  Some computer systems may "recognize" the date of service as a previously submitted date of service and will "kick out" the claim as a duplicate, even though the claim was not actually paid when originally submitted.   

 

The best defense is a good offense!

 

Following the instructions above will expedite the correct processing of your claim but it is often necessary to submit these claims several times before they are properly adjudicated.  Double check all of your claims before submitting and make sure you send your claims directly to HNS, not to the address on the insurance cards. 

 

Carefully review the HNS Claims Checklist and the "Corrected Claims" section under the tab "CA Help Desk" before submitting claims to HNS.