Expenses Incurred Prior to Coverage PR 26 Denial Code

Payers will deny the claims with CO 26 Denial Code – Expenses incurred prior to coverage, whenever the providers perform health care services to patient prior to the insurance coverage starts.

What steps needs to be taken?

• Review other claims in the application within a span of 30 days, to see if any claims were paid and find out whether we have receive payment from the same insurance or not?
• If the paid claim has same insurance ID, then check the eligibility to confirm the patient was effective, eligible and active at the time of health care service rendered? If the above condition is satisfied, call the payer claims department and have the claim reprocessed.
• If not, check the application was there other insurance involved in paying those claims. If yes, submit the claim to the valid insurance which is eligible and active at the time of service provided.
• Review previous notes in the application to see any updates of new policy details.
• Review path for any scanned copies of insurance information in the application.
• If any of the new insurance information available, check eligibility of new insurance, update the insurance details in application, and then resubmit the claim to the appropriate insurance for reimbursement.
• If not, bill the patient or place a call to patient requesting active insurance details.

Call the Claims department and ask the following question to resolve the CO 26:

1. First get the date of received and denial of the claims?
2. Next, check the effective date of the patient health insurance policy to know when the insurance coverage starts to take the necessary action as per the denials?
3. Check the termination date of the insurance policy to know when the health insurance coverage of patient is inactive and take necessary action?
4. After verification with representative, if patient policy was effective, eligible and active for date of service, then send the claim back for reprocessing.
5. If suppose patient was not effective, not eligible and not active at the time service provided, check with representative and find out any other health insurance details for particular patient which is active and eligible at the time of service rendered.
6. Finally, get the Claim number and Cal reference number of the denied claim from representative.

 Learn More…

Insurance Denial Code CO-27 – Coverage Terminated

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