Clean Claim Revisited
‘Clean Claim’ denials are the most common reasons for nonpayment of a bill and is explained on the EOR as “Claim contains incomplete/missing other procedure and /or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.”
The most common errors on the CMS 1500 which result in this denial include:
Box 10a – Should reflect ‘Y’ if services are related to a work related injury;
Box 14 – Incorrect date of injury, please call MSF if you do not have this date. It is also listed on the EOR.
Box 24J – Missing rendering provider which typically coincides with the provider name listed in Box 31;
Box 32 and/or 32a – If place of service is other than 12 (home), then Box 32 must denote the facility name and physical address where services were provided. Box 32a must include the NPI for this entity;
Box 33a – Missing the NPI for the billing provider.
A word about NPI (National Provider Identifier) numbers – The NPI number is matched with the name and number registered on the NPPES (National Plan & Provider Enumeration System). If the name and NPI on the bill does not match the name and NPI on NPPES, the bill will deny. Please ensure service facilities used in Box 32 are registered on the NPPES website.
Other Denials and/or Reason Codes Defined
Procedure insufficiently identified or quantified:
The documentation does not support the code billed,or
the documentation may be incomplete, or
a DME item dispensed to the injured worker is not documented in the note, or
the E/M level billed is not supported by the submitted documentation.
Timed procedure – submit time:
A code with a time element is billed, but the time spent per service or modality is not documented in the note.
Claim denied – not compensable:
The claim as a whole is deemed not compensable so is not accepted as a Workers’ Compensation
The service that is being billed is deemed unrelated to injury of record. If the documentation submitted includes work done for conditions not related to the injury the bill may be denied in whole or by line depending upon the services billed with the corresponding diagnosis. If an injured worker is seeking treatment for unrelated conditions, they should be seen at a separate appointment.
Payment of this bill does not constitute acceptance of conditions/injuries not directly related to the injury of record:
This reason code is not a denial but is used if there are conditions/injuries mentioned in the documentation that are not being treated at the appointment or that are difficult to separate out and advises that payment of the bill does not mean that any unrelated problems are not considered accepted as part of the Workers’ Compensation claim.
Indicates that the injured worker is represented by an attorney who has argued for and won medical coverage related to a workers’ compensation claim. Lockhart was a 1999 Supreme Court Decision “Lockhart vs New Hampshire Insurance “ which states in part “attorney lien codified at § 37-61-420, MCA, applies to medical benefits recovered due to the efforts of an attorney in a worker’s compensation case…”
Indicates that a claim has a designated treating provider assigned. This was part of HB334 and refers to Montana Code Annotated (MCA) 39-71-1101 which became effective July 1, 2011. The designated treating provider is responsible for the management and coordination of care of an injured worker including filling out the work status form at each visit and defining the treatment plan within the Utilization and Treatment guidelines of the injured worker. The designated treating provider receives 110% of the Montana Non-Facility Fee Schedule.
Indicates a provider other than the designated treating provider and receives 90% of the Montana Non-Facility Fee Schedule when there is a treating provider designated on a claim.