 Denials / Problem Claims
We are excited to announce that our CNC Practice Protection Plan has been added to the secure portion of our website. This Practice Protection Plan includes important information about post-payment audits, the CNC Documentation Requirements, payor policies, and valuable coding and billing information as well as valuable forms and templates that we hope will help you protect your practice. Please print this material and review it with your staff. As always, if you have any questions, please contact your CNC Provider Representative.
CNC IS COMMITTED TO REDUCING YOUR DENIALS!
In our efforts to reduce your denials from the insurance plans we represent, CNC returns "paper" claims to your office for correction when we believe that the claim is incompletely or inaccurately completed and will result in a denial of the payment for that claim. Please be aware that this is service provided to your by CNC to facilitate the prompt payment of your claims. If you are unclear about the reason that a particular claim was returned, please contact your CNC Provider Rep and fax her copy of the claim TOGETHER with the CNC Claim Return Form and we will assist you in correcting the claims.
To reduce the number of claims returned to your office, make sure you have obtained current insurance information before submitting them to CNC! Contact your CNC Provider Representative if you need assistance. We want to do everything possible to assist you in the prompt payment of all claims submitted to CNC.
TOP REASONS WHY PAPER CLAIMS ARE DENIED
1. Sending "CNC" claims DIRECTLY to the
insurance company/payor rather than to CNC
Improperly submitting your "CNC" claims DIRECTLY to the insurance companies or payors, rather than to CNC, is the NUMBER ONE REASON INSURANCE COMPANIES/PAYORS DENY YOUR "CNC" CLAIMS!
In addition to negatively impacting your collections, improperly submitting claims directly to the insurance company or payor causes significant problems for our managed care partners and repeated improper submission of claims can jeopardize your continued participation in our network. Please make sure that all staff members and/or billing companies understand the importance of sending your "CNC" claims directly to CNC.
HOW TO AVOID THESE DENIALS
Require all staff members to learn which contracts are CNC contracts that must be sent to CNC.
Post a list of CNC contracts in various places throughout your office for easy reference
for all staff members.
Make sure that the CNC address, NOT THE ADDRESS OF THE INSURANCE COMPANY, is in your computer, for each CNC contract, to assure that the CNC address always prints on the top right hand corner of the HCFA 1500! If using windowed envelopes, this will assure that your claims are sent to CNC, not to the insurance company. If you are MANUALLY addressing your claim envelopes, please make certain that you address the envelope using the CNC address below:
CNC
PO Box 2368
Cornelius, NC
28031.
NEVER address the envelopes to the address on the insurance card or to any address given to you by representatives of the insurance companies. Ignore any instructions regarding where to send claims given to you by representatives of the insurance companies. CNC instructions regarding where to send claims supersede ALL OTHER INSTRUCTIONS!
IF YOU ARE EVER UNSURE ABOUT WHERE TO SEND A CLAIM, PLEASE USE YOUR CNC FAX FORM AND FAX A COPY OF BOTH THE FRONT AND BACK OF THE MEMBER'S INSURANCE CARD TO CNC. WE WILL GLADLY ASSIST YOU!
WHAT TO DO IF YOUR EOB/NOP SHOWS THIS DENIAL
If you DO mistakenly send a claim directly to the insurance company or payor you must wait until you receive an EOB/NOP showing a denial of your claim BEFORE resubmitting the claim. There is no need to call the insurance company, payor or CNC in order to have the claim reprocessed. Simply follow the instructions below:
Generate a new HCFA for the date(s) of service
STAPLE a copy of the EOB/NOP showing the denial to the claim
Mark the claim "CORRECTED CLAIM"
SEND THE CLAIM TO CNC:
CNC
PO BOX 2368
CORNELIUS, NC
28031
Upon receipt, CNC will manually resubmit the claim.
IT IS VERY IMPORTANT THAT YOU SEND THESE CLAIMS MARKED "CORRECTED CLAIM" AND FOLLOW THE INSTRUCTIONS ABOVE.
Please be aware that for certain insurance companies, reprocessing a previously submitted claim is often a lengthy and difficult process. Some computer systems may "recognize" the date of service as a previously submitted date of service and will "kick out" the claim as a duplicate, even though the claim was not actually paid when originally submitted. Following the instructions above will expedite the correct processing of your claim but it is often necessary to submit these claims several times before they are properly adjudicated. The best defense is a good offense! Double check all your claims before submitting and make sure you send your claims directly to CNC, not to the address on the insurance cards!
2. Incorrect member ID Number
Submitting claims with an INCORRECT or INCOMPLETE member identification number in box 1A on the HCFA 1500 is the number TWO reason that insurance companies/payors deny your "CNC" claims!
HOW TO AVOID THESE DENIALS
There can be several reasons for denials associated with a member's ID number such as:
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Failing to include any suffix (such as 01) that appears on the members ID card when completing the HCHA 1500.
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Incorrectly entering the member's ID in your computer
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Transposing numbers when completing box 1a on the HCFA 1500
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Failing to include all alpha prefixes
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Failing to include suffixes, if applicable
-
Member presents with an invalid insurance card.
To reduce these denials, OBTAIN A COPY OF THE MEMBER'S ID CARD ON ON EVERY VISIT.
VERIFY THE NAME OF THE INSURED AND/OR THE NAME AND ID NUMBER OF THE PATIENT WHEN CALLING TO VERIFY BENFITS. VERIFY EFFECTIVE DATES OF COVERAGE.
Verify that the member ID number in your software system is EXACTLY THE SAME as the number of the insurance card, including all alpha prefixes and any suffixes, if applicable. Please remember that ID numbers can change at anytime throughout the year and members often forget to inform you if they have a new ID number! By obtaining a copy of the card at each visit, then verifying that the ID number in your computer matches the number on the card, you can significantly reduce your denials!
Always send a copy of the front and back of the member's insurance card to CNC (stapled to the claim) WHENEVER THERE IS A CHANGE IN THE MEMBER'S INSURANCE INFORMATION. (It is only necessary to do this the FIRST TIME that you submit a claim following the change in the insurance information)
Include a copy of the front and back of the insurance card with your claim, when FIRST submitting claims on ANY NEW PATIENTS TO YOUR PRACTICE.
WHAT TO DO IF YOUR EOB/NOP SHOWS THIS DENIAL
Generate a new HCFA for the date(s) of service
STAPLE a copy of the EOB/NOP showing the denial to the claim
Mark the claim "CORRECTED CLAIM"
SEND THE CLAIM TO CNC:
CNC
PO BOX 2368
CORNELIUS, NC
28031
Upon receipt, CNC will manually resubmit the claim.
If you receive a denial associated with an incorrect member ID number or other incorrect insurance information, first check the ID number on your copy of the member's ID card against the number in your computer. If you find an error, then follow the instructions below for resubmitting the claim. If the number on the EOB/NOP is different than the number in your computer, please follow the instructions below for resubmitting the claim. If you are unable to determine the cause of the problem or if you are unsure about the correct ID number, ALWAYS contact the member and ask them to provide you with a copy of their most current insurance card. Once you receive this card, contact the payor and verify the ID number and coverage dates! Then follow the instructions below for resubmitting the claim.
Once you have contacted the insurance company/payor and verified that you have the correct insurance ID number, there is no need to contact CNC in order to have the claim reprocessed. Simply follow these instructions carefully:
3. Non-covered services
Denials from insurance companies/payors for services that are non-covered services is the third leading reason for denials of "CNC" claims! Chiropractic benefits vary according to each plan and you should always verify benefits for every member before beginning treatment or anytime there is a change in insurance information. Please remember that the CNC fee schedules should NEVER be used to determine covered services!
HOW TO AVOID THESE DENIALS
ALWAYS CONTACT CNC FOR ASSISTANCE IN DETERMINING IF A SERVICE IS CONSIDERED NON-COVERED BY A CNC CONTRACTED PAYOR.
Please remember that the information that you received when verifying benefits is subject to corporate medical policy for chiropractic so the payor representatives may tell you that the service is a covered service and then the service will be denied based on corporate medical policy.
While most providers routinely verify chiropractic benefits, many providers fail to get SPECIFIC benefit information for each member and/or do not realize that information provided by phone representatives is subject of corporate medial policy, which can result in a denial for services rendered that are non-covered services.
Once you determine that chiropractic services are covered, ALWAYS ask if there are ANY restrictions regarding:
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the number of visits/manipulations per year
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number of therapies per visit
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frequency of radiographs
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bundling of manipulation or other codes
-
any other restrictions to the plan
- preexisting conditions
We also recommend that you obtain both the first and last name of the person providing you with benefit information and note the full name and date of call on your benefit verification checklist. Having this documented will be helpful should a dispute arise regarding a covered/non-covered service.
Anytime you receive an EOB or NOP showing a denial code that you believe to be an error, please remember that these services are either paid or denied by the insurance company or payor, not by CNC. CNC DOES NOT MAKE DECISIONS REGARDING THE PAYMENT OR DENIAL OF ANY CLAIMS. EOB'S/NOP'S included with your CNC remittance are sent to CNC from the Insurance companies or payors and we pass them on to you. To assist you with understanding the action taken by the insurance companies or payors, a description/explanation of the denial code is always included with the EOB/NOP. Please contact your CNC Provider Rep for assistance in understanding why a particular claim or service was denied. We are here to help!
Once you have determined WHY the insurance company or payor denied a particular CPT code (or codes) and you believe that the claim should be reconsidered for payment, then follow the instructions below for resubmitting the claim.
Generate a new HCFA for the date(s) of service
Mark the claim as "CORRECTED CLAIM"
STAPLE a copy of the EOB/NOP showing the denial to the claim
CNC
PO BOX 2368
CORNELIUS, NC
28031
Important note:
If you contact the insurance company or payor about a problem with an EOB/NOP and are told to resubmit a new claim, please remember that you must ignore any instructions that you may receive on the phone regarding where to send the claim and send all paper claims for CNC payors directly to CNC.
ADDITIONAL HELPFUL INFORMATION ABOUT YOUR CLAIMS
Denial code 42 and 45.
Denial codes 42 and 45 are inappropriate denial codes for all CNC contracts but payors occasionally use these codes as "generic" denials. We have seen these denials codes used for the following reasons:
when there is a problem with dates of coverage versus service dates
incorrect member ID number on the claim
name of insured on claim is incorrect
payor believes that member has secondary coverage
payor has requested additional information from the provider and has not received it.
Resolving these denials can be frustrating and time consuming. If you receive an EOB with one of these denial codes, we recommend that you immediately contact the payor. However, BEFORE addressing the inappropriate denial code, always start the call by verifying the member's ID number, effective dates of coverage, and the name of both the member and the insured. This may reveal the real reason for the denial. Once you have verified that this information is correct, then ask for their assistance in explaining the denial code. Always remember , anytime you resubmit a claim that has already been denied, mark the claim as a CORRECTED CLAIM, STAPLE the EOB showing the denial to the new HCFA 1500 and send to CNC.
Denial code 16
You will occasionally receive an EOB/NOP from the insurance companies/payor with a denial code 16.
This code means that additional information is required before the claim can be processed.
If you receive an EOB/NOP with this denial code 16, please do not call CNC. CNC has no way of knowing what information is needed to adjudicate your claim. You must contact the insurance company or payor DIRECTLY to find out what specific information is needed. Once you have obtained the requested information, please follow these instructions:
Generate a new HCFA 1500 for the date(s) of service that denied
Attach (staple) a copy of the EOB/NOP showing the denial to the HCFA 1500
Attach (staple) the requested information to the HCFA 1500
DO NOT SEND TO THE INSURANCE COMPANY OR PAYOR. YOU MUST SEND THIS CLAIM TO CNC!
(IGNORE ANY INSTRUCTIONS GIVEN TO YOU BY REPRESENTATIVES OF THE INSURANCE COMPANY/PAYOR REGARDING WHERE TO SEND THIS INFORMATION!)
SEND TO:
CNC
PO BOX 2368
CORNELIUS, NC 28031
WE WILL MANUALLY SUBMIT TO BE PROCESSED.
Secondary Coverage/Coordination of Benefits
CNC providers are required to file for secondary coverage anytime the primary or secondary coverage is a CNC contract. Please pay close attention when completing your HCFA 1500 if there is secondary coverage. Make sure to mark "YES" in box 11d on your claim form as well as completing BOXES 9a-d on the HCFA 1500! These boxes must be completed when submitting claims to the primary carrier as well as the secondary carrier.
Filing for secondary coverage is the same process for each CNC contract.
You must file with the primary carrier first. Once you receive the EOB/NOP from the primary carrier, then generate a new HCFA 1500, making sure that all appropriate boxes are completed, then staple the EOB to the new HCFA and send to CNC.
Filing with BCBS as secondary to Medicare requires the same process! (While Medicare automatically crosses to BCBS, those claims are denied since the claim did not come through CNC first.) Just follow the process above for coordination of benefits for Medicare/BCBS claims.
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