denials and problems with your claims

CNC IS COMMITTED TO REDUCING YOUR DENIALS!

To assist you with reducing the number of claims that are denied by the insurance companies, CNC utilizes a series of custom edits to help identify certain errors and/or "problem" claims that if sent to the payors, would likely result in the denial of payment for those claims.

If errors are found on claims submitted electronically via ChiroTrack®, those claims will be rejected and the system will notify you of the specific problem with each claim, so you can quickly correct the claim and resubmit it. Claims with errors will NOT be submitted to the payor until all errors have been corrected.  Because it takes up to 24 hours for our systems to check your claims and identify any claims with errors, you must check the status of your claims on ChiroTrack® 24 hours after you have submitted the claims, so you can correct your errors and the claims can then be transmitted to the payor(s) for adjudication.

Paper claims submitted to CNC via the CMS 1500 form are also checked for certain problems that could cause the claim to deny and such claims will be returned to you with a CNC Claim Return Form. This form will identify the specific problem with the claim. When CNC returns a paper claim with our Claim Return Form, please make the appropriate corrections and return the claim to CNC, together with the CNC Claim Return Form.  Please do not mark the claim Corrected as CNC will know it is corrected by the return of the CNC Claim Return Form. CNC will then process and submit the claim to the payor for adjudication.

CNC developed these custom edits and procedures to assist in assuring your claims are correctly adjudicated the first time they are submitted to the payor. While these edits cannot prevent all denials, they greatly reduce the number of your claims that are denied by the payors.

If you have any questions about why a claim rejected on ChiroTrack® or why a paper claim was returned to you with the CNC Claim Return Form, please contact your CNC Provider Rep for assistance.

The following lists contain the most common reasons why your claims may encounter denials or problems during adjudication.

The most common reasons why your claims are denied or rejected by the payor(s) are:

1. Incorrect or incomplete insurance ID number

2. The date of birth on the claim does not match the member's date of birth on file with payor

3. Member not covered on the date of service

4. Service provided is not a covered benefit under the member's plan

5. Claims were submitted directly to the insurance company, rather than to CNC

The most common problems with a claim during adjudication:

1. The claim has been previously submitted for adjudication (i.e. - duplicate claim)

2. "Split" claim - the services rendered on one date of service are divided between two or more claims. (for example, the manipulation printed on one claim, and the therapies printed on a different claim.)

3. Incorrect group number was placed in box 11.

4. Date of Onset (box 14) was not placed on the claim.

5. Incorrect or missing modifiers.

How to avoid these denials:

1.  Incorrect member ID Number

Submitting claims with an INCORRECT or INCOMPLETE member identification number in box 1A on the CMS 1500 claim form is the number ONE reason that insurance companies/payors deny your claims.

There can be several reasons for denials associated with a member's ID number such as:

• Failing to include any suffix (such as 01) that appears on the members ID card when completing the CMS 1500 claim form
• Incorrectly entering the member's ID in your computer
• Transposing numbers when completing box 1a on the CMS 1500 claim form
• Failing to include all alpha prefixes
• Member presents with an invalid insurance card.

To reduce these denials, always obtain a current copy of the member's ID card at each visit and be sure that you update your practice management software with the correct information BEFORE transmitting the claim to CNC.

When verifying benefits, always verify the complete name and subscriber ID number, as well as dates of coverage and covered benefits.  Verify that the member ID number in your software system is EXACTLY THE SAME as the number on 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 the ID number in your computer matches the number on the card, you can significantly reduce your denials.

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 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! 

2.  Incorrect Date of Birth on the Claim

It is very important to check ALL information on a claim prior to submitting the claim. When the payor cannot recognize the patient, the payor will not properly adjudicate the claim. Often the insurance company cannot identify the patient because the patient ID number does not match the patient date of birth. This error occurs most often with patients who have other family members (dependents) enrolled under the same plan.

When payors are reviewing a claim, the subscriber ID number is the first area that is checked.  Some payors have specific ID numbers for different family members and others use the same ID number. However, in either case, the payor will confirm the patient information against the patient date of birth in box 3 on the CMS 1500 claim form to confirm that the patient listed on the claim has coverage for the date of service submitted.

To avoid these denials, always:

• Verify the patient date of birth with the payor
• Correctly input the date of birth into your computer prior to submitting claims.

3.  Member has no coverage on date of service

Many denials result from claims submitted for members who have no coverage on the date of service. Such denials can be avoided by properly verifying effective dates of coverage.

Insurance plans renew and change throughout the year, not just in January!  A patient's employment status can change or their insurance plan may change with their current employer. The patient may not remember to tell you of any changes, so it is very important for you to ask if any changes have occurred and make a copy of their insurance card on EACH visit.  Be sure to update your practice management software system with any new information prior to submitting any claims.

You can reduce the number of these denials by the following actions:

• Obtain a current insurance ID card on every visit.
• Check effective dates of coverage for each member.
• Update your computer system with current insurance information.

4.  Non-covered services

It is imperative that you always verify benefits prior to rendering chiropractic services. It is also imperative you verify each service is covered when provided by a chiropractor.

You can reduce the number of these denials by the following actions:

• Obtain a current insurance ID card on every visit.
• Verify that each service you intend to provide is a covered service and is covered when provided by a chiropractor.
• Use the CNC Verification of Insurance Form or a similar one that you have created.
• If a service is non-covered, do not bill the insurance company. The service is NON-COVERED.
• If a service is non-covered, have the patient sign a waiver agreeing to pay for the non-covered service, PRIOR to performing the service.
• Always maintain the signed waiver in the patient's health care record.

Please remember that the information that you receive when verifying benefits is subject to payor corporate medical policies for chiropractic. A payor representative may tell you that the service is a covered service and then the service will be deny 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 to corporate medical 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:

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, time 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 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!

5. 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 a primary reason insurance companies 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 all staff members and/or billing companies understand the importance of sending your CNC claims directly to CNC. 

You can reduce the number of these denials by the following actions:

• Post a list of CNC contracts in various places throughout your office for easy reference for all staff members.

• Require all staff members to learn which contracts must be sent to CNC.

• Make sure the CNC address, NOT THE ADDRESS OF THE INSURANCE COMPANY, is in your computer, for each CNC contract, to assure the CNC address always prints on the top right hand corner of the CMS 1500 claim form.  Using window envelopes 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 you address the envelope using the CNC address below, rather than the address of the insurance company.

                                                               CNC

                                                               PO Box 2368

                                                               Cornelius, NC  28031

Ignore any instructions regarding where to send claims by payor phone representatives.  CNC instructions regarding where to send claims supersede all other instructions given by payor representatives when verifying eligibility and benefits.

IF YOU ARE EVER UNSURE ABOUT WHERE TO SEND A CLAIM, PLEASE USE YOUR CNC FAX INQUIRY FORM AND FAX A CLEAR, LEGIBLE COPY OF THE FRONT AND BACK OF THE MEMBER'S INSURANCE CARD TO CNC.  WE WILL GLADLY ASSIST YOU!

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 of your claims before submitting and make sure you send your claims directly to CNC, not to the address on the insurance cards.

If you receive an EOB showing an incorrectly processed CPT code or any other processing error, PLEASE FOLLOW THESE INSTRUCTIONS: