Remark code MA62 indicates: Alert: This is a telephone review decision. This means that the payment or denial decision made on the claim was determined following a review conducted via telephone. Healthcare providers should be aware that additional information regarding this decision may be available and can often be obtained by referencing the accompanying notes or by contacting the payer directly if clarification is needed.
Common causes of code MA62 are:
1. The claim contains charges for services not covered by the payer because they are considered to be the responsibility of another insurer or third party.
2. There is a lack of coordination of benefits (COB) information indicating that another payer should have been billed before the current claim was submitted.
3. The services were provided during a period in which another payer was primary, and the current payer was secondary or tertiary.
4. The claim was submitted for a beneficiary who has Medicare, and Medicare has not been billed as the primary payer when it should have been.
5. The claim includes charges that are typically covered by a property and casualty insurer, such as in the case of an auto accident or workers' compensation case.
6. The services may be related to a legal settlement, and the payer requires additional information to determine financial responsibility.
7. The patient may have a supplemental insurance policy that should have been billed for the services prior to the claim being submitted to the current payer.
Ways to mitigate code MA62 include implementing a robust documentation process that captures all necessary information during patient interactions. Ensure that staff are trained to understand the importance of detailed record-keeping, especially for services that may require a telephone review. Utilize a checklist for phone consultations to guarantee that all relevant details are noted and can be easily referenced if a review is requested. Regularly audit phone consultation notes to ensure they meet the required standards and are comprehensive enough to support the decision made during the telephone review. Establish a clear communication channel with the payer to quickly address any issues or questions they may have regarding a telephone review decision.
The steps to address code MA62 involve initiating a follow-up to understand the specifics of the telephone review decision. Begin by reviewing the patient's medical records and the claim documentation to ensure that all services billed were medically necessary and properly documented. Next, contact the payer's provider relations or appeals department to request details of the telephone review, including any concerns or reasons for the decision. Based on the information gathered, prepare a comprehensive appeal that includes any additional documentation or clarification that supports the medical necessity and appropriateness of the services billed. Submit the appeal in accordance with the payer's guidelines and timelines, and monitor the claim status regularly to ensure a timely response. If the appeal is denied, consider escalating the issue through higher levels of the payer's appeals process or seeking assistance from a healthcare attorney or advocacy group if appropriate.