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CO 22 Denial Code

Avoiding claim denials can feel like going through a complex maze for healthcare providers. Understanding the CO 22 denial code and implementing effective strategies can be a gamechanger for you. This blog delves into the CO 22 denial code in detail and focuses on its causes. We also highlight several practical solutions to prevent it.

Continue reading to ensure smoother billing operations for your healthcare facility.

What is CO 22 Denial Code?

The denial code 22 is given in a claim whenever a medical service may be covered by another insurer. Its coverage is based on the coordination of benefits. This coordination applies to those patients who have several insurance policies.

In this case, their primary insurance company usually denies the claim. The company believes any of the other insurers of those patients should cover the cost. The Coordination of Benefits should classify the insurers of patients into primary, secondary, and tertiary companies.

This action is crucial so that the relevant payment is not done twice. Also, the correct insurance company should pay the correct amount. The denials related to the 22 denial code are made whenever secondary payments are not made without the details from the first ones.


CO 22 Denial Code

When Is Coordination of Benefits Needed?

There can be several instances that necessitate the involvement of Coordination of Benefits. Both spouses in a married couple can either be covered by their own group or individual coverage. This is either through their employer or an independent insurer respectively.

In this case, the primary policy would be where the patient is the primary policyholder. Another case involves a spouse who declares the other one as a dependent in their policy. This coverage would be secondary although plans can vary based on domestic partner coverage rules.

A married couple with children can have the insurance of one parent as primary. Their birthday (month/date) would have to fall first in the calendar year. This is known as the “birthday rule” where the other parent’s coverage becomes secondary.

Some parents can have the same birthday (month/day). In this case, the primary policy has the longest effective date. The Affordable Care Act implementation enables parents to cover their dependents through their insurance plans.

This can be done until the age of 26 with no regard to the dependent’s student or marital status. A family unit can get complex, or the insurance type may not be the standard group or an individual plan. In this case, the coordination of benefits coordination can get complicated.

Consider this example: one of the parent’s coverage is provided by COBRA. The full form of COBRA is the Consolidated Omnibus Budget Reconciliation Act. The non-COBRA and COBRA plans become primary and secondary respectively. This rule is applicable regardless of the birthday rule.

In case of divorced parents, the coordination depends on the custodial parent. A parent can also be considered if their child spends the most time with them. In this case, they will have primary coverage. Whereas the non-custodial parent will have a secondary policy.

Although, an exception can be applied to this rule. A custodial parent can have an individual policy or COBRA. The non-custodial parent with a group policy will be considered primary. Moving on, there is a consideration if the custodial parent remarries.

In this case, the secondary policy goes to the stepparent. Whereas the non-custodial parent will have a tertiary plan. There can be a divorce decree initiated in the form of court order to override these rules. It can also override the individual state laws that include custodial parents and minors.

Common Reasons for the CO 22 Denial Code

There can be various reasons as to why your reimbursement claim is denied with code 22. Let’s take a look at them in detail:

  • Incorrect Insurance Details and Lack of Prior Authorization

This code is usually triggered due to certain errors in the insurance details provided. These details are primarily about group numbers, policy numbers, and subscriber information. This is a major reason that causes a large portion of the total claim denials.

You have to get prior authorization from insurers for specific medical services before you provide them. There can be instances where a provider does not obtain the necessary authorization. A lack of authorization can be made the reason to deny their claim with code 22.

  • Late Filing and Out-of-Network Providers

You can only submit your reimbursement claims to insurance companies within specific timeframes. Some claims end up being filed after the allowed time limit. As a result, they are also eligible to be denied with code 22. This happens due to healthcare providers failing to submit them within the required timeframes.

Moreover, you may also currently not be in the patient’s insurance network. This can lead to your claim getting denied with code 22. For such cases, the code is given as a patient needs to seek care from an in-network provider.

  • Coverage Termination and Non-Covered Services

It is also possible that the insurance coverages of specific patients are either terminated or expired. This is another reason as to why you get code 22 with your claim denials. It may happen if the insurance policies of those patients were not renewed at that time. The insurance coverage may also have been terminated if they did not renew their policy.

Their insurance company may also randomly terminate their coverage. It is important to note here that certain medical services may not come under a specific patient’s insurance plan. This leads to the claims getting CO 22 in their denials.

How to Avoid CO 22 Denial Code?

Healthcare providers can adopt various strategies to prevent their claims from getting denied due to CO 22 denial code. We have covered them in great detail for you:

CO 22 Denial Code

  • Preventing Incorrect Insurance Details

It is crucial to carefully verify patient insurance information. This can include details such as the group number, policy number, and subscriber details. This has to be done before submitting claims. By doing this, you can prevent errors that lead to claim denials. You should confirm specific details with what is on file to ensure accuracy.

These details can be the patient’s name, date of birth, or insurance ID. Your staff should cross-reference this information with the insurance card. You can also do this with the data in the system to catch any discrepancies early on.

Encourage patients to update their insurance details promptly whenever there are changes. This includes changes in employment, marital status, or any new insurance coverage. Establish a protocol for your patients to provide updated insurance information.

This should be done at every visit. You should also send periodic reminders to them to verify their insurance details. Electronic eligibility verification systems are also invaluable tools. You can use them to confirm insurance coverage in real-time.

These systems reduce the likelihood of claim denials. They do that by recording current and valid insurance details. By using these tools, you can instantly verify coverage and understand co-payments. This way, any restrictions on the patient’s insurance plan can be easily detected.

  • Ensuring Prior Authorization

Familiarize yourself with the procedures and services that require prior authorization from insurers. Each insurance plan can have different requirements. Maintain a detailed list of such procedures and services to optimize the process.

Submit their authorization requests well before the scheduled service. This can help avoid delays and potential denials. It is also beneficial to have a dedicated team or individual. They should be responsible for handling prior authorizations.

By doing this, your requests can be made in a timely manner. Keep a detailed record of all authorization requests and approvals as well. This is vital for future references. You should especially document the main details.

They include the date of submission, authorization number, and any communications with insurers. This documentation can be helpful in case of any disputes or follow-ups needed.

  • Meeting Filing Deadlines

Be aware of each insurance company’s specific claim submission deadlines. Different insurers have varying time limits. You should file all your claims within them. Missing these deadlines can land you in automatic denials. Submit your claims as soon as possible after providing relevant services. This practice keeps you within the allowed window.

Implement all the billing steps as close to each other as possible. For example, you should attempt to submit all the claims within the same day. Set up a system to monitor your claim submissions. This system should also be able to identify any approaching deadlines.

It can be a software that alerts your staff to pending deadlines. Conduct regular audits of the submitted claims to identify and address any potential issues. This way, you can solve them before they become problematic.

  • Staying In-Network

Whenever possible, choose providers within the patient’s insurance network. This can minimize out-of-pocket costs for your patients. It can also reduce the likelihood of claim denials related to out-of-network services.

Confirm the participation of your patient’s insurance provider in their coverage plan. This involves checking the insurance company’s directory. You can also contact their office to directly verify the network status. In some cases, an out-of-network provider can be necessary.

Then, you should clearly explain the potential for higher costs and claim denials to the patient. Provide them with a detailed explanation of their financial responsibilities. This can help them manage expectations and prevent surprise bills.

  • Addressing Coverage Issues

Regularly check for upcoming insurance expiration dates for your patients. This ensures that their coverage is active at the time of service. Set up a reminder system that can alert staff and patients when renewals are due. Consider sending your patients friendly reminders to renew their insurance coverage.

This can be done through automated emails, texts, or phone calls. Ensure continuous coverage to avoid gaps and prevent claim denials. Familiarize yourself with the specific exclusions and limitations of each insurance plan. This can help avoid submitting claims for non-covered services.

You will have to understand the benefits, limitations, and exclusions of the patient’s policy. Train your staff to review and understand insurance plans. This way, they can prevent unnecessary denials and ensure the coverage of all medical services.

How Health Quest Billing Helps Prevent Claim Denials?

Health Quest Billing prevents claim denials for hospitals. We do that by conducting comprehensive insurance verification. We also ensure accurate patient coverage details. Our billing experts also optimize the prior authorization process. It is done through automated requests and proactive follow-ups.

We also prioritize detailed documentation management and regular audits. Other practices include efficient claims submission and electronic processing. We always meet deadlines and reduce as much billing errors as possible. Moreover, Health Quest Billing has a dedicated denial management team.

It handles all the claim denials and appeals effectively. Patient financial education and cost transparency remain our top priorities as well. We help our patients understand their responsibilities. Our advanced reporting and analytic tactics track claims in real-time.

They are able to provide us valuable insights for improvement. Another key service is technology integration with EHR systems. This integration ensures seamless data flow and automated alerts for potential issues.

The Bottom Line

Understanding and addressing the CO 22 denial code is the key to preventing its denials. You can do it through accurate insurance verification, timely prior authorization, and efficient claims submission.

Health Quest Billing has a comprehensive approach that enables you to maneuver through these challenges effectively. Contact Health Quest Billing to optimize your revenue cycle and enhance patient satisfaction.

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Frequently Asked Questions (FAQs)

Denial code 22 indicates that a medical service may be covered by another insurance provider. This is indicated based on the coordination of benefits.

Medical billers should carefully review all the denied claims. They should check for any inaccuracies and verify the relevant patient benefits.

You should integrate a digital COB solution. This should be done within the registration and scheduling workflows.

The appeal for such claim should be filed within 180 days of receiving the relevant denial notice. In normal cases, insurers determine if the appeal holds any merit for either a preauthorization or coverage denial.

Coding and billing errors are the most common reasons for claim rejections. Billers can make mistakes in assigning medical codes to the relevant services.