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INSURANCE DENIALS

Learn what are different types of Insurance denials and why Insurance may deny the claims and how to handle denials in medical billing.

CO 6 Denial: The procedure code is inconsistent with the patient's age
  CO 6 Denial Code: The procedure/revenue code is inconsistent with the patient's age When the claim says CO 6 Denial Code – The Procedure/revenue code is inconsistent with the patient’s age, it means claim denied as the CPT code or revenue code billed is not compatible with patient age. Let us...
Denial Code CO 204 - Not Covered under the Patient's current benefits plan
  Denial Code CO 204 - Not Covered under the Patient's current benefits plan   With a valid Advance Beneficiary Notice (ABN): PR-204: This service, equipment and/or drug is not covered under the patient's current benefit plan PR-N130: Consult plan benefit documents/guidelines for information about restrictions for this service Without a valid ABN: ...
CO 119 - Benefit Maximum for this Time Period has been Reached
  (MEDICARE DOES NOT PAY FOR THIS MANY SERVICES OR SUPPLIES) CO -119 Benefit maximum for this time period or occurrence has been reached. Check Benefit Information through website/Calls If NO - Call the carrier and send the claim back to reprocess. PR - 119 Benefit maximum for this time period or occurrence has...
Insurance denial CO 39: Authorization/Referral Problem
  Insurance denial CO 39: Services denied at the time Prior authorization/pre-certification was requested Some carriers insist on obtaining prior authorization from them before the surgery.  This may be for certain specific procedures or may even be for all procedures.  So these are carrier specific and procedure specific. Please note that it...
Denial Code CO 47: Diagnosis Missing or Invalid
  Denial Code CO 47: Diagnosis Missing or Invalid   Insurances Company will be denying the claim with  CO 47 Denial Code: This (these) diagnosis (es) is (are) not covered, missing, or are invalid, whenever the Diagnosis CPT code is not Valid or missing. Diagnosis Code is Invalid The payer is indicating that one...
Insurance Denial CO 38: Services Not Authorized by Providers
Insurance Denial CO 38: Services Not Authorized by Providers There are a number of reasons that insurance providers require prior authorization, including age, medical necessity, the availability of a generic alternative, or checking for drug interactions. A failed authorization can result in a requested service being denied or in an...
CO-10 Denial Code: Diagnosis Code is Inconsistent with the Patient's gender
  DENIAL CODE CO-10: The diagnosis code is inconsistent with the patient’s gender Insurance will deny the claim with CO-10 denial code – The diagnosis code is inconsistent with the patient’s gender, when the diagnosis code is not compatible with the patient’s age. Let us consider the below examples to understand CO-10...
What is Prompt-pay Discount? Adjustment Code CO-44.
  Healthcare providers sometimes offer "prompt-pay discount" to encourage patients to pay their bills within a certain period, including outstanding copayments or deductible amounts. Such programs should be structured appropriately to ensure compliance with applicable laws and payer contracts. The legal rules differ by state. California law, for example, allows healthcare providers...
Denial CO 11: Diagnosis is inconsistent with The Procedure
  Denial Code CO 11 – The diagnosis is inconsistent with the procedure Insurance will deny the claim as Denial Code CO 11. Whenever the Procedure code billed with an inappropriate diagnosis code. Diagnosis code (DX Code): Diagnosis code represents the description of the disease. These codes are assigned by medical coding department...
CO12 Denial Code: Diagnosis is inconsistent with the Provider Type
  CO12 Denial Code: Diagnosis is inconsistent with the Provider Type Insurance will deny the claim as Adjustment Code CO 12 – The diagnosis is inconsistent with the provider type, whenever the Procedure code billed with an inappropriate diagnosis code. Diagnosis code (DX Code): Diagnosis code represents the description of the disease. These codes...