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Denial reason CO-22 or PR-22 & CO-19 - Tips to correct these denials


Claim Adjustment Reason Codes (CARC) CO-22 or PR-22 This care may be covered by another payer per coordination of benefits. CO-19 This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

You may also receive a Remittance Advice Remark Codes (RARC) N127 This is a misdirected claim/service for a United Mine Workers of America (UMWA) beneficiary. Please submit claims to them.

Reason for this denial:

Medicare may not be a Primary payer for the services / procedures rendered on a particular date of service. Medicare Secondary Payer (MSP) claims can be denied for one or more of the following reasons:

Secondary payment cannot be considered without the identity of, or payment information from, the primary payer. The information was either not reported or was illegible.

The patient’s care should be covered by another payer per coordination of benefits.

Our records indicate that we should be the third payer for this claim. We cannot process this claim until we have received payment information from the primary and secondary payers.

Claim denied because this is a work-related injury and, thus, the liability of the workers’ compensation carrier.

Claim denied because this injury/illness is the liability of the no-fault carrier.

Payment is adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments.

Tips to aviod this denial:

Providers must know beforehand where to file the initial claim:

Traditional Medicare?

An employer sponsored group insurance plan?

Medicare Advantage plan?

Patient screening is the way for providers to obtain valuable information necessary for proper claims submission. Claim rejections and/or denials will occur if complete patient insurance information is not obtained or kept up to date. Providers are required to file claims based on information obtained from the patient prior to submitting the claim.

Be familiar with the MSP guidelines and incorporate the MSP requirements into the patient screening process to ensure the information obtained will assist with proper claim submission.

Verify the patient’s Medicare card and other insurance cards and retain a copy for your files.

Verify and re-verify the patient’s eligibility information regularly to ensure the office information is up to date and accurate.

The IVR will provide patient eligibility and benefit information to assist in determining if Medicare is secondary and the effective dates.

The Coordination of Benefits Contractor (COBC) can assist with situations where there is a conflict between the CWF and Medicare records. Providers may contact the COBC for assistance with MSP issues as well as to alert the COBC of an accident/injury. COBC information can be found in the Medicare Secondary Payer (MSP) manual as well as on the CMS Web site.

Contact the COBC to:

report employment changes, or any other insurance coverage information;

report a liability, auto/no-fault, or workers’ compensation case;

ask general MSP questions/concerns;

ask questions regarding MSP letters and questionnaires.

Contact National Government Services to:

answer your questions regarding Medicare claim or service denials and adjustments;

answer your questions concerning how to bill for payment;

process claims for primary or secondary payment;

accept the return of inappropriate Medicare payment.

The COBC’s trained staff will help you with your COB questions. Whether you need a question answered or assistance completing a questionnaire, the customer service representatives are available to provide you with quality service. Also see 'CMS and COBC initiatives for Updating Beneficiary Information with the Coordination of Benefits Contractor (COBC)'

View additional coordination of benefits information on the CMS Web site at http://www.cms.gov/COBGeneralInformation/01_Overview.asp.

View additional MSP information on the CMS Web site in the CMS IOM Publication 100-05, Medicare Secondary Payer Manual
 

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