Below is a list of denial codes/reason as to why claims are denied by the health insurance companies, each with through explanation and potential solution on how to address the denied claim if possible. Please read through the entire explanation for each denial reason, if you still have questions please reach out to the Pear Suite billing team. 

The claim/service has been transferred to the proper payer/processor for processing. Claim/service not covered by this payer/processor. (code B11)

• When you seeing this denial reason, the health plan is stating that the claim that was submitted to the health plan was submitted to the incorrect payer and the claim has been redirected to the correct health plan. This denial reason is commonly seen when a claim is created for a member with insurance coverage from one health plan but actually has insurance coverage from a different health plan. For example when the member says they have Health Net insurance but they actually have Molina insurance.
   
• To solve and prevent this denial reason, there are 2 potential solutions. The first being to check the eligibility of the member and determine the coverage details of the member. You can use the eligibility tool on the Pear Suite platform to check the eligibility and coverage details of the member. The second potential solution is to reach back out to the member and reconfirm the coverage details from the member by asking if the member has a insurance card or other documentation to confirm their coverage. Once the member’s insurance coverage is confirmed, you might have to update the member’s insurance coverage information to the correct coverage details on the member’s profile and all activities that are being billed so that the claims are sent to the correct health plan. For any claim that has already been submitted and denied, the claims will have to be submitted as a corrected claims but will still need to have the corrected insurance coverage details on the denied claims.
  
  
  • The eligibility tool on the Pear Suite Platform can be accessed by going to the members profile and where the insurance information is detailed, there is a little green circle with a question mark in the middle. If you click on the little green circle with a question mark and click “Get Details” on the pop up window. The platform will expand the pop up window with the member’s coverage details. The other method to access the eligibility tool is to go on the claims page and select a claim. On the right side of your screen you will see the “Claims Details” panel, scroll down to the green link that says, “View coverage details”. If you click on the link the platform will open up the eligibility tool pop up window. Now that you are on the eligibility tool pop up window, scroll down to “Plan Basic Details”, section ****you will see if the coverage is active or not. Then scroll down again to the “Plan Benefit” section and look under the “Health Benefit Plan Coverage” tab to see the coverage details which will indicate which health plan the member has coverage with.

The procedure code is inconsistent with the modifier used

• This denial reason is indicating that the claim was denied because of the procedure code used on the claim for the services rendered has a modifier that does not follow the contractual billing guidelines for the services that were rendered. When seeing this error, reach out to the billing team and the customer success team member to investigate the error, because a possible cause for this error is the system configuration on the Pear Suite platform and may require the Pear Suite team to review. If the source of the error is on the Pear Suite platform, the Pear Suite team will find a solution. However if the error resides on the side of the payer, the Pear Suite billing team will work with both the health plan and the client to find a solution in addressing the error.
• To prevent this denial reason, when creating claims be sure to check the claim modifiers match the procedure code billing guidelines. If there is a change that needs to be made please notify the Pear Suite team. By checking and confirming the modifiers match the procedure code guidelines with the health plans, this error will be reduced in frequency and if the error continues to persist the error can be take to the health plans to investigate the error.

Precertification/authorization/notification/pre-treatment absent. (code 197).

• This denial reason is indicating that either a Provider Recommendation or Plan of Care needs to be submitted for the member’s claims. Please keep in mind, even though DHCS has issues a standing order for the first 12 units of service, the health plans may still require the pre/authorization documentation for services to be rendered to the member.
• To prevent or address this error. If your member has not sent a claim and this error occurs, please reach out to the Pear Suite billing team to file a Provider Recommendation and resubmit the claim as a corrected claim. If the member has a number of claims that have already been submitted, review the number of units of service that the member has already billed for and if the member has 10 units or more billed and the member requires more units of service. Complete a Request for Authorization for Additional Units and send the completed form to the Pear Suite billing team at cin_check@pearsuite.com. Once complete the form will be sent to the respective health plan and you can continue to bill for the member.

Expenses incurred during lapse in coverage (code 200)

• This denial reason is indicating that when the member received the rendered services, the member was did not have active coverage during the date of service. The most likely case is the member’s coverage had either recently expired and is getting renewed or the member was switching health insurance coverage from one health plan to another.
• Unfortunately, for this denial reason there is not a solution to resolve the denial, because of the gap in the member’s coverage and claims date of service is within that gap of time.

Diagnosis was invalid for the date(s) of service reported.

• This denial reason is stating the diagnosis code was invalid during the date(s) of service on the claim. This is due to several issues, including invalid or incorrect diagnosis codes, a mismatch between the diagnosis code and the date of service, lack of specificity in the diagnosis code, or non-adherence to payer-specific guidelines such as using a preferred primary diagnosis code.
   
• How to resolve this denial reason.

1. Review Claim Details: Carefully examine the submitted claim for any errors in diagnosis codes, dates of service, or other relevant fields.
2. Verify Diagnosis Code Validity: Ensure that the diagnosis code used is current, specific, mark as primary if necessary and applicable to the date of service and the patient's condition.
3. Check Payer Guidelines: Consult with your Customer Success Team Member and if possible the specific payer's policies for any restrictions or requirements related to the diagnosis code and service provided.
4. Correct and Resubmit: If an error is identified, correct the claim with the appropriate information. Enter the original reference number to regenerate the claim as an reissue and proceed to submit it for processing.

Claim/service lacks information or has submission/billing error(s). (code 16)

• This denial reason means that your insurance claim was processed with a reduction in payment (adjustment) because of a contractual agreement between you and the payer, and the claim itself was also denied or adjusted further due to missing information or errors in the submission or billing. This denial code, CO 16, indicates that the claim is missing essential details needed for proper adjudication or contains errors in the billing process.
• This denial reason could also mean when a claim is denied for Missing Explanation of Benefits (Coordination of Benefits or Medicare billed as Secondary Payer). Which indicates that the claim is missing required information about coordination of benefits (COB) or Medicare Secondary Payer (MSP). This means the payer needs an Explanation of Benefits (EOB) from the primary insurance or Medicare to properly process the claim.
• Essentially, the denial reason is stating that the member has more than one health insurance coverage or the member has Medicare listed as the secondary insurance on their coverage. Because Pear Suite bills the member’s primary insurance, when a claim is denied for this reason, it means the payer needs an Explanation of Benefits (EOB) from the primary insurance or Medicare to properly process the claim, however because no EOB is submitted with the claims or Medicare is not listed as the primary insurance the payer denies the claim.
• To solve for this denial reason, the user would have to reach back out to the member to collect the correct primary insurance information and update that information on the member’s profile. Then regenerate the claim with the correct primary insurance information for the activity on the claim and proceed to submit the claim for review.

Exact duplicate claim/service (CO-18).

• This denial code CO-18 signifies an "Exact Duplicate Claim/Service," meaning the payer has identified that a claim submitted is identical to one that has already been processed or submitted for the same patient on the same date of service or within a similar timeframe. This denial often results from issues like accidental double-billing activities on a single claim, or failure to update claim information before submission.

Benefit maximum for this time period or occurrence has been reached. (code 119)

• The denial reason indicates that an insurance plan has paid out the maximum amount it will cover for a specific service or treatment within a given timeframe or for a particular instance, leading to a denial of further claims for that item. This often occurs when a patient's insurance benefits, such as annual or lifetime maximums for certain services, have been exhausted.
• To address this denial reason, start by checking the number of units that have been billed for the member who received the denial reason. If the member has more than 12 units services already billed, then the user will need to request an Authorization for Additional Units for the member. Once the Authorization for Additional Units is completed and sent to the Pear Suite team to submit, the user may continue to bill for rendered services for the member. Start by sending one claim to test if the additional units are approved for the member and once the claim gets into the accepted status, then continue to bill claims for the member.

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

• This denial reason (CO-45), means the healthcare provider billed the insurance company an amount higher than what's stipulated in their contract or the payer's established fee schedule. Essentially, the insurance company is refusing to pay the full billed amount because it exceeds their agreed-upon reimbursement limit.
• To address this denial reason, start by checking the number of units that have been billed for the member who received the denial reason. If the member has more than 12 units services already billed, then the user will need to request an Authorization for Additional Units for the member. Once the Authorization for Additional Units is completed and sent to the Pear Suite team to submit, the user may continue to bill for rendered services for the member. Start by sending one claim to test if the additional units are approved for the member and once the claim gets into the accepted status, then continue to bill claims for the member.