CNC's Role in Claims Processing

We often receive faxes and calls from our providers asking why CNC denied a claim or why we applied a charge to a co-payment or deductible as well as other questions that involve the adjudication of claims.  As such, we thought it would be helpful to clarify CNC's role in processing your claims.

CNC does not adjudicate claims.  CNC makes no decisions regarding the payment or denial of any services submitted to the payor through CNC.  All such decisions are made by the insurance company, managed care organization and/or payor and are subject to member eligibility, payor corporate medical policies and plan limitations. 

Only the insurance company/payor determines whether your claim is denied or paid!   The payor explains the reason for the action taken for each CPT on the EOB/NOP and this information is included with your CNC remittance.  (This is normally indicated by a remark code or reason code.)  Additionally, CNC has no information regarding WHY a claim may be denied or paid by a payor bull will gladly assist you with understanding the reason codes on the EOB or NOP and will also contact the payor, when applicable, for clarification.

Additionally, CNC has no information regarding your patient's insurance coverage or benefits and has no role in applying co-payments or deductibles when processing your claims. The insurance companies/payors check benefit and coverage information on each member before processing claims and adjudicate claims based on relevant policies as well as each member's coverage.

It is particularly important to verify specific services such as orthotics, acupuncture and/or any other services that might not routinely be considered a service provided by chiropractors and we urge network providers to first contact CNC for clarification regarding the appropriateness of any "non-standard" or atypical service, prior to performing such service.

CNC receives your claims at our central claims administration office.  Before processing,  we submit ALL claims to a series of edits designed to identify claims with errors or problems that will likely deny if submitted to the payor as is.  If we determine that submitting your claim will likely result in a denial of your claim, we return the claim to you along with the Claims Return Form, to let you know what information is needed or should be changed.  We provide this service to assist you in getting your claims paid as quickly as possible! 

Once we have reviewed your claims, claims are separated into 2 groups: those that must be sent by paper and those that will be sent electronically.  Over 98% of CNC claims are sent electronically to the insurance company/payor. Each business day, an electronic file is created containing all claims entered into our system during that day.  That file is then electronically sent to the appropriate insurance or managed care company for adjudication.  Within 24 hours, CNC confirms that the electronic file was received by the payor by obtaining an acknowledgment from the insurance company/payor that the file(s) were successfully transmitted and received for processing.  This assures us that all claims submitted to CNC were successfully sent to the insurance company or payor for adjudication.

Claims requiring special handling and all claims with attachments, (such as secondary claims with primary EOB'S attached) are keyed into our system then sent by paper, via US Mail, directly to the insurance company/payor for adjudication.

CNC has no more involvement in the claims processing process until your claim is adjudicated by the payor.

Once the claim is adjudicated by the payor, the payor sends any remittance due to the provider to CNC, together with the EOB's/NOP's to support whatever action has been taken.  CNC receives these remittances and EOB'S on a daily basis from our managed care partners.  We post all monies received each day under the appropriate CNC provider's name, much like you post payments to your patients accounts and we file all EOB's that were included with the remittance in each provider's file.  On the 10th, 20th and 30th of each month, we then forward to you any monies and EOB's received since the previous CNC check-cut date, NOT including monies received after the check cut process begins.  

( When tracing claims, please remember if you are told that a payor has issued payment to CNC within the last 10 days, this payment will likely be on your next scheduled check cut from CNC.   Payments received immediately prior to our check cut dates cannot be issued until the next scheduled check cut.)

While all claims received by CNC are logged into our system before being sent to the insurance company/payor, they are batched and logged as a BATCH FILE and are not tracked by individual claims within the file.  You can be confident that if you send a claim to CNC, it will be sent to the appropriate insurance company or payor for adjudication.   However, If you do not receive any correspondence for a particular claim in 60 days or longer, we recommend that you contact CNC to determine if we received your claim.  CNC can inform you of the date the claim was sent to the insurance company or payor but we have no information as to the status of your claim, once it has been sent for adjudication.  However, if you need our assistance, we will be happy to trace the claim for you.

We want to assist you whenever possible and while we have no role in the adjudication process of your claims, questions regarding the denial of any claims that first processed through CNC should be faxed to CNC, together with the CNC Fax Inquiry Form and we will gladly assist you.