Denial code 23 is used to indicate that the claim has been denied due to the impact of prior payer(s) adjudication, which includes payments and/or adjustments. This denial code is typically used in conjunction with Group Code OA.
Common causes of code 23 are:
- Incorrect payment or adjustment by prior payer(s): This code may be triggered if the prior payer(s) made an error in processing the claim, resulting in an incorrect payment or adjustment. It could be due to miscalculations, misinterpretation of the claim details, or system glitches.
- Inadequate documentation: Insufficient or incomplete documentation provided with the claim can lead to code 23. If the necessary supporting documents are missing or do not meet the payer's requirements, it can result in a denial or adjustment.
- Non-covered services: Code 23 may indicate that the services rendered are not covered under the patient's insurance plan. This could be due to policy exclusions, limitations, or the service being deemed medically unnecessary.
- Coordination of benefits (COB) issues: When a patient has multiple insurance coverages, coordination of benefits becomes crucial. Code 23 might be assigned if there are discrepancies or conflicts in the coordination of benefits process, leading to payment or adjustment issues.
- Incorrect coding: Errors in coding, such as using the wrong procedure or diagnosis codes, can result in code 23. If the codes submitted on the claim do not align with the services provided, it can lead to payment discrepancies or denials.
- Timely filing limits exceeded: Insurance companies have specific timeframes within which claims must be submitted. If the claim is filed after the allowed time limit, it can result in code 23. Late submissions may be denied or adjusted due to the expiration of the timely filing window.
- Duplicate claims: Submitting duplicate claims for the same service can trigger code 23. Insurance companies typically have policies in place to prevent duplicate payments, and if they identify multiple claims for the same service, they may adjust or deny the subsequent claims.
- Contractual agreements: Code 23 may be related to contractual agreements between the healthcare provider and the payer. If there are discrepancies or violations of the agreed-upon terms, it can result in payment or adjustment issues.
It is important for healthcare providers to identify the specific cause of code 23 in order to address the issue and take appropriate action to resolve the denial or adjustment.
Ways to mitigate code 23 (Group Code OA) include:
- Verify eligibility and benefits: Before providing any healthcare services, it is crucial to verify the patient's eligibility and benefits with the primary payer. This will help you understand the coverage details and any prior adjudication that may impact the claim.
- Accurate documentation: Ensure that all medical documentation is accurate, complete, and supports the services provided. This includes documenting the medical necessity of the services, any prior authorizations obtained, and any other relevant information that may be required for claim submission.
- Timely claim submission: Submit claims to the primary payer in a timely manner. Delays in claim submission can increase the chances of denials due to prior payer adjudication. Establish efficient processes to ensure claims are submitted promptly after the services are rendered.
- Follow-up on outstanding claims: Regularly monitor the status of submitted claims and follow up on any outstanding or unpaid claims. This will help identify any issues related to prior payer adjudication and allow for timely resolution.
- Appeal denied claims: If a claim is denied due to prior payer adjudication, it is important to review the denial reason and determine if an appeal is warranted. Follow the appeal process outlined by the primary payer to provide additional information or clarification to support the claim.
- Stay updated with payer policies: Keep abreast of any changes in payer policies and guidelines that may impact claim adjudication. Regularly review updates from the primary payer to ensure compliance with their requirements and minimize the chances of denials related to prior payer adjudication.
- Utilize technology and automation: Leverage technology solutions and automation tools to streamline the revenue cycle management process. This can help reduce errors, improve efficiency, and minimize the risk of denials related to prior payer adjudication.
By implementing these strategies, healthcare providers can proactively mitigate code 23 (Group Code OA) and minimize the impact of prior payer adjudication on their revenue cycle.
The steps to address code 23 (The impact of prior payer(s) adjudication including payments and/or adjustments. Use only with Group Code OA) are as follows:
1. Review the Explanation of Benefits (EOB) or Remittance Advice (RA) from the prior payer(s) to understand the details of their adjudication process.
2. Compare the payments and adjustments made by the prior payer(s) with the expected reimbursement based on the contracted rates and fee schedules.
3. Identify any discrepancies or underpayments that may have occurred during the prior payer(s) adjudication process.
4. Gather all necessary supporting documentation, such as copies of claims, medical records, and any additional information required by the prior payer(s) for reconsideration or appeal.
5. Contact the prior payer(s) directly to discuss the specific code 23 denial and provide any additional information or clarification they may require.
6. Follow the prior payer(s)'s specific process for submitting a reconsideration or appeal, ensuring that all required forms and documentation are completed accurately and submitted within the designated timeframe.
7. Keep a record of all communication with the prior payer(s), including dates, times, and the names of the individuals spoken to, for future reference.
8. Monitor the status of the reconsideration or appeal and follow up with the prior payer(s) as necessary to ensure timely resolution.
9. If the prior payer(s) upholds the denial or does not provide a satisfactory resolution, consider escalating the issue to a higher level within the prior payer(s)'s organization or seeking assistance from a healthcare revenue cycle management expert or consultant.
10. Continuously evaluate and improve your internal processes to minimize the occurrence of code 23 denials in the future, such as ensuring accurate and complete documentation, verifying eligibility and benefits prior to services, and staying updated on the prior payer(s)'s policies and reimbursement guidelines.