pr22 denial code

(2022) How To Correct Denials Codes CO 22, PR 22 & CO 19

It is frustrating when a claim is denied with CO 22, PR 22, or CO 19. We explain why these denials happen and how to prevent them.

1. What Is Denial Code CO 22?

Denial CO 22 occurs when a claim is denied because it is already covered by another payer per coordination of benefits (COB).

The official definition of CO 22 is: “This care may be covered by another payer per coordination of benefits (COB).”

The main reason for the denial CO 22 is that the patient’s coordination of benefits (COB) is not up-to-date. Another reason can be that Medicare does not insure the patient.

2. What Is Denial Code PR 22?

Denial PR 22 happens when a claim is denied because it is already covered by another provider per the coordination of benefits.

The official definition of PR 22 is: “This care may be covered by another payer per coordination of benefits.”

Denial PR 22 occurs when secondary payment can not be considered because of a lack of information about the primary payer.

3. What Is Denial Code CO 19?

Denial code CO 19 occurs when the claim is work-related. The injury is, therefore, the responsibility of the workers’ compensation carrier.

The official definition of denial code CO 19 is: “This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier.”

4. Six Reasons For Denial CO 22, PR 22, Or CO 19

Denial CO 22, denial PR 22, or denial CO 19 often occurs when Medicare is not the primary payer. Below you can learn why the claims are denied. You can correct a claim if you know why it was denied.

1.1. Reason 1

Information about the primary payer was not complete or reported because the secondary payment can not be processed without payment information and the identity of the primary payer.

1.2. Reason 2

The payment of the claim is adjusted. Adjustment is made because of the impact of previous payer(s) adjudication. Payments and/or adjustments are included.

1.3. Reason 3

The claim is denied because the illness or injury billed is the no-fault carrier’s responsibility.

1.4. Reason 4

A denial occurred because the injury was work-related and, therefore, the responsibility of the workers’ compensation carrier.

1.5. Reason 5

A third-party payer can’t process the claim because payment information of the primary and secondary payers needs to be submitted.

1.6. Reason 6

Another payer should cover the claim and is responsible for the patient’s care per the coordination of benefits.

2. How To Prevent Denial Codes CO 19, PR 22, Or CO 22

Before billing a claim, you should ask yourself the following questions.

  1. Is this part of the Medicare advantage plan?
  2. Is the claim part of an employer-sponsored group insurance plan?
  3. Is the claim traditional Medicare?

Denial CO 19, PR 22, or CO 22 can be avoided if the providers screen the patients before the procedure is provided. Unfortunately, denials often occur when the provider fails to obtain the necessary information.

Ensure you understand the MSP guidelines and requirements and how they are part of the patient screening process.

Denial CO 22, PR 22, or CO 19 often occurs when insurance information about the patient is not up to date. Ensure the provider double-checks this information before providing any services.

Make a habit of verifying and re-verifying insurance information about patients to prevent denials of CO 22, PR 22, or CO 19.

The patient’s Medicare card needs to be verified, and a digital or a hard copy of the card should be kept in the patient’s files.

IVR can assist you in seeing if the patient information is complete and if Medicare is the secondary payer.

Check the MSP manual (Medicare Secondary Payer) or the fact sheet from the CMS website for COBC information.

TIP: You can download the MSP Fact Sheet Here.

COBC can help you with conflicts between Medicare records and CWF.

3. Correcting Denials By Contacting COBC

Sometimes, you should contact COBC to correct denials CO 22, PR 22, and CO 19.

Contact COBC if you;

  • have a question about MSP letters and questionnaires;
  • have MSP questions/concerns;
  • want to report a liability, auto/no-fault, or workers’ compensation case; or to
  • report employment changes.

4. Correcting A Claim By Contacting National Government Services

You may want to contact National Government Services for the following reasons.

  1. To accept the return of inappropriate Medicare payment.
  2. For processing claims for secondary or primary payment.
  3. Questions about how to bill payment.
  4. Questions about Medicare denials and/or adjustments.

References

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R313CP.pdf

https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MSP_Fact_Sheet.pdf

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