No-fault insurance injury/illness Denial CO-21

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No-fault insurance injury/illness Denial CO 21
CO 21: Claim denied due to a no-fault carrier

 

In the same way insurance will deny the claim with CO-21 Denial Code – This injury/illness is the liability of the no-fault carrier, when the healthcare claim billed is responsibility of the no-fault insurance.

What is No-fault insurance?

If you’re injured in a car accident, your own car insurance coverage will pay some or all of your out-of-pocket or economic losses, regardless of who was at fault for the crash.

No-Fault insurance means that your own auto insurance carrier takes care of costs that were incurred as a result of an injury sustained in an auto accident (e.g., medical bills, wage loss, replacement services claims). Your insurance carrier pays the benefits without regard as to who may be at fault for the accident.

These benefits are first-party or policyholder benefits and may also be referred to as Personal Injury Protection coverage or “PIP” for short. This coverage is mandatory in most No-Fault states.

There are currently 12 states that have No-Fault insurance with benefits ranging from $3,000 in medical expense (Utah) to unlimited medical benefits (Michigan).

No-Fault benefits typically include a set amount for payment of reasonable expense of necessary medical treatment, in addition to benefits available for wage loss, replacement services, funeral and burial expense, and survivors’ economic loss benefits. Depending on the state law, there may be additional or fewer benefits available to the injured party.

They are mainly State Owned Policies and the claims supposed to be submitted with various bills or documents and they are as follows:

  • Accident Report from the patient.
  • FIR or First Injury Report from the Police
  • Medical Records from the provider and
  • Witness reports from the witnesses.

We need to first follow the below steps to resolve the issue:

  • Review other Date of service with same CPT/DX code to conclude if they were processed as medical or injury related.
  • Review patient documentation to ascertain if the healthcare service pertains to injury.
  • If claim submitted is injury related and coverage of liability insurance or no fault carrier, update the appropriate details and submit the claim along with medical records.
  • If the liability carrier or no fault carrier information not available, then check with patient to update the required information.

Learn More…

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