Monday, July 19, 2010

CMS 1500 - COMMON REJECTION

Claims commonly reject for the following reasons:


2. Provider and/or recipient eligibility was not established on the dates of services
covered by the claim.


��
Verify that you did not bill for services provided prior to or after your provider enrollment dates.

�� Verify that you entered the correct dates of service in the Block #24a of the claim form. You must call EVS on the day you render service to determine if the recipient is eligible on that date. If you have done this and your claim is denied because the recipient is ineligible, double-check that you entered the correct dates of service.

�� Verify that the recipient is not part of the Medical Assistance HealthChoice Program. If you determine that the recipient is in HealthChoice, contact the appropriate Managed Care Organization (MCO).

�� Verify that the recipient is not covered by Medicare. If you determine that the recipient is covered by Medicare, bill the appropriate Medicare carrier.


3. Preauthorization is required.

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Certain procedures require preauthorization. If you obtain preauthorization, verify that you entered the number correctly in Block #23 on the claim. If you did not obtain preauthorization, remove the unauthorized procedure from the claim and resubmit the claim to receive payment for the procedures that do not require preauthorization.

�� When billing for preauthorized procedures, verify that the dates of service entered on the claim are the same dates of service that were authorized.



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