Pathology/Lab Coding Alert

Question: If we know that the Medicare contractor has made a mistake in denying one of our claims, should we just send it through again?

Arkansas Subscriber

Answer: Simply re-sending a denied claim probably won’t solve the problem, and will almost certainly cost you more time and effort in the long run.

The Medicare contractor denied the claim for a particular reason during the first round of submission. If you don’t address that reason now, your claim will likely return to you as a denial again. What’s worse, once a payer has processed a claim for a date of service, they will detect the duplication in the date of service and CPT® code(s) and deny the service(s) as a duplicate claim. Then you’re dealing with two denials.

Possibilities: Many things can go wrong that will result in an erroneous denial. Problems with patient pre-authorization, place of service, physician credentials, an oversight on your part on the claim, or problems with the Medicare contractor’s processing systems are just a few things that could all cause an incorrect denial.

Best practice: Rather than automatically resending the claim, contact your Medicare contractor representative. Discuss the denial with the representative, and figure out why Medicare denied the claim. A short phone call could save you much more time in the long run.

Usually, you’ll need to send a corrected claim and an appeal, explaining why the claim should be paid, what coding rules were utilized for the claim, and the documentation. Those steps can help you get paid on a claim that was improperly denied.