In essence, the insurance company you billed believes another insurer is primarily responsible for the payment. Understanding and effectively managing CO 22 denial code is critical for maintaining a healthy revenue cycle and ensuring timely reimbursements.
This comprehensive guide will break down the CO 22 denial code, explore its common causes, and provide actionable strategies for prevention and resolution. We’ll also cover frequently asked questions to help you navigate this challenging denial.
What is CO 22 Denial Code?
The CO 22 denial code is a Claim Adjustment Reason Code (CARC) used by insurance payers to indicate that a healthcare service might be covered by a different insurance provider due to Coordination of Benefits (COB) rules. This typically occurs when a patient has more than one active insurance policy, and the primary insurer denies the claim, directing the provider to bill the secondary (or even tertiary) insurer first.
Think of it like this: If a patient has two insurance plans, Plan A and Plan B, and you bill Plan A, but Plan A believes Plan B should pay first according to COB rules, you’ll receive a CO 22 denial code. This doesn’t mean the service isn’t covered, but rather that the claim was sent to the wrong payer or in the wrong order.
Why Do You Get a CO 22 Denial Code? Common Causes
The prevalence of the CO 22 denial code stems from various factors, mostly related to inaccurate or incomplete patient and insurance information:
- Coordination of Benefits (COB) Issues: This is the most common reason. When a patient has multiple insurance plans (e.g., through two employers, or a primary and a secondary plan like Medicare and a private insurer), COB rules dictate which plan is primary, secondary, etc. If claims are submitted out of this established order, a CO 22 denial code will likely occur.
- Incorrect Patient Insurance Information: Even a minor error in patient details like name, date of birth, insurance ID number, or group number can lead to a CO 22 denial code. The system might not be able to verify the patient’s identity or eligibility, leading to the assumption that another payer is involved or the information is simply wrong.
- Missing or Outdated Insurance Information: If the patient’s insurance coverage has changed, expired, or was terminated, and your records aren’t updated, submitting a claim to an inactive policy will result in a CO 22 denial code. Similarly, if a patient has new coverage they haven’t disclosed, it can cause COB confusion.
- Failure to Obtain Prior Authorization: While not directly a COB issue, a lack of required prior authorization for a service can sometimes trigger a CO 22 denial code if the payer sees it as a service not covered by them without that pre-approval, implying another payer might cover it. However, it’s more often linked to other denial codes (e.g., CO 204).
- Late Filing: If claims are not submitted within the timely filing limits of a particular insurance payer, they may be denied with a CO 22 denial code or other time-limit-related codes. While not a direct COB issue, it can complicate the resolution of a COB problem if the secondary payer also has strict filing deadlines.
- Duplicate Claim Submissions: Accidentally submitting the same claim multiple times can also lead to a CO 22 denial code if the system flags it as already processed or indicating a primary/secondary payer confusion.
- Out-of-Network Provider: If a provider is out-of-network for a patient’s primary insurance, the claim may be denied, sometimes with a CO 22 denial code, as the primary insurer might suggest the patient seek an in-network provider or that a secondary plan (if one exists) might offer some coverage.
Impact of CO 22 Denial Code on Your Revenue Cycle
CO 22 denial code can significantly disrupt your healthcare practice’s revenue cycle:
- Delayed Payments: Each denial means delayed reimbursement, impacting cash flow.
- Increased Administrative Burden: Resolving CO 22 denial code requires additional staff time for research, phone calls to payers and patients, and resubmission.
- Potential Revenue Loss: If not addressed promptly and correctly, denied claims can eventually become uncollectible, leading to lost revenue.
- Patient Frustration: Patients may receive unexpected bills, leading to confusion and dissatisfaction.
How to Prevent and Resolve CO 22 Denial Code: A Step-by-Step Guide
Proactive measures and a systematic approach are key to minimizing and resolving CO 22 denial code.
Prevention Strategies:
Robust Patient Registration and Insurance Verification:
- Verify at Every Visit: Implement a strict protocol to verify patient insurance information at every visit, not just the first one. Ask patients if their insurance has changed.
- Collect All Insurance Information: Ensure front-desk staff gather details on all active insurance policies a patient may have (primary, secondary, etc.).
- Utilize Eligibility Verification Tools: Leverage technology to automate eligibility and benefits verification before services are rendered. This helps identify primary/secondary payer relationships upfront.
- Educate Patients: Inform patients about the importance of providing accurate and up-to-date insurance information.
Thorough Understanding of COB Rules:
Train Staff: Continuously train billing and front-office staff on COB rules and guidelines, as these can vary by payer and state.
Document COB Clearly: Have clear internal protocols for determining the correct order of benefits for patients with multiple insurance plans.
Accurate Data Entry:
- Double-Check All Information: Emphasize accuracy in data entry for patient demographics, policy numbers, group numbers, and effective dates.
- Leverage Practice Management Software: Use software that can help flag potential errors or missing information.
- Proactive Prior Authorization: For services requiring pre-approval, ensure it’s obtained and documented before the service is provided to avoid related denials.
- Timely Claim Submission: Always adhere to each payer’s timely filing limits.
Resolution Steps (When you receive a CO 22 denial code):
Review the Denial Notice and EOB: Carefully examine the Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) for the specific reason for the CO 22 denial code and any associated remark codes (e.g., MA04: “Secondary payment cannot be considered without the identity of or payment information from the primary payer.”).
Verify Patient’s Insurance Information and COB:
- Contact the Patient: Reach out to the patient to confirm their current insurance plans and their primary/secondary status. Use a Medicare Secondary Payer (MSP) Questionnaire if applicable for Medicare patients.
- Contact the Payer: Call the denying insurance company to understand why they denied the claim and if they have information about a primary payer.
- Identify the Correct Primary Payer: Based on your review and communication, determine which insurance plan is truly primary.
Resubmit the Claim to the Correct Payer:
If the original submission was to the wrong primary payer, correct the information and resubmit the claim to the identified primary insurer.
If the original submission was to the primary payer, and they denied it saying another payer is primary, then submit the claim to that identified “other” primary payer.
Submit to Secondary Insurance (if applicable): Once the primary payer has processed the claim, obtain their Explanation of Benefits (EOB). If there’s a patient balance or remaining amount, submit a claim to the secondary insurance, attaching the primary payer’s EOB.
Appeal if Necessary: If you believe the Denial code was issued in error (e.g., your records clearly show your billed payer is primary), gather all supporting documentation and initiate an appeal with the insurance company.
FAQs about CO 22 Denial Code
Q1: What is the most common reason for a CO 22 denial?
The most common reason is Coordination of Benefits (COB) confusion, where the claim is submitted to the wrong insurance company or in the incorrect primary/secondary order.
Q2: How can I prevent CO 22 denials proactively?
Implement thorough patient registration and insurance verification processes, including verifying coverage at every visit, utilizing eligibility verification tools, and ensuring accurate data entry for all patient and insurance information.
Q3: What information do I need to resolve a CO 22 denial?
You’ll need the denial notice/EOB, the patient’s full and accurate insurance details (including all active policies), and potentially information on COB rules from the insurance payers.
Q4: Can a CO 22 denial be appealed?
Yes, if you believe the denial was incorrect, you can appeal. You’ll need to provide documentation proving that the insurance plan you billed is indeed the primary payer, or that there is no other coverage.
Q5: How does CO 22 differ from other common denial codes?
While other codes address issues like lack of medical necessity (CO 50), missing information (CO 16), or duplicate claims (CO 18), CO 22 denial code specifically points to an issue with which payer is responsible based on Coordination of Benefits. It’s unique in its focus on multi-payer scenarios.
Q6: What if the patient has no other insurance, but I still get a CO 22?
This can happen if the insurance company’s records are outdated or incorrect. In this case, you’ll need to contact the patient to reconfirm their insurance status and then contact the insurance company to update their records. You may need to provide an affidavit from the patient stating they have no other coverage.
Q7: Is it always the patient’s fault for a CO 22 denial?
Not necessarily. While incomplete or outdated information from the patient is a common cause, errors can also occur during registration, data entry by billing staff, or due to complex or changing COB rules.
Conclusion
The CO 22 denial code is a pervasive challenge in medical billing, but it’s far from insurmountable. By understanding its underlying causes, implementing robust preventive measures, and following a systematic approach to resolution, healthcare providers can significantly reduce its occurrence and impact. Proactive insurance verification, meticulous data entry, and continuous staff training are your strongest defenses against this common denial, ultimately leading to a more efficient and financially stable revenue cycle.