Chapter 13: Commercial Insurance Carriers

Rejected Claim
A claim that does not contain the necessary information for adjudication.
180 Days
If a provider wishes to submit for a first level provider payment review form Cigna, what is the timeframe for this type of dispute?
Valid proof of timely filing
When submitting reconsideration to Cigna for timely filing, what must be included?
2 steps: Reconsideration, Level 1 and Level 2 appeals
How many steps are in the Aetna dispute and appeals process, and what are those steps?
Claim covered by other insurer
Which denial occurs when the claim is a liability case and was submitted to the health insurance?
Which modifier is used to indicate that an E&M service is unrelated to the global service?
Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service is which modifier?
Patient Protection and Affordable Care Act
What act includes provisions for the appeals process?
12 months
For United Healthcare, a reconsideration must be submitted within this timeframe of the date of the EOB or RA.
Incorrect patient information
What is one of the leading reasons a claim is rejected and can be prevented by accurate intake information being collected every time?
Denied Claim
Claim that passed through the payer’s initial claim processing, but was determined not to be a covered service or procedure based on the payer’s coverage criteria
Insurance benefits should be verified before major services are rendered
Common denials occur when the patient’s coverage was not in effect on the date of service submitted for reimbursement. How can this be avoided?
False (termination date only found by verifying eligibility)
T or F: Insurance cards typically have both an effective date and the termination date
24 to 72 hours
Retroactive authorization may be
considered within this timeframe of the service being rendered, depending on the payer’s guidelines
No prior authorization/referral
This type of denial may frequently occur with HMO patients
Exclusions or non-covered services
Refer to certain medical services excluded from the payer’s health
insurance coverage under the patient’s plan
How much is the patient’s responsibility for non-covered services?
Coordination of benefits (COB)
The process of determining which of two or more insurance policies will have the primary responsibility for paying a claim, and the amount that the other policies will contribute
COB denial
Type of denial that may be related to the fact that a secondary insurance was billed as a primary insurance by mistake
Claim Covered by Other Insurer
Type of denial that occurs when the claim is a liability case
A primary payment has been made, or when an appeal has been denied.
Depending on the payer, timely filing limits begin when either of these two things occur.
T or F: If a claim has been adjudicated and a decision made, the claim is closed by the payer
A duplicate claim denial will be sent
If a claim has been adjudicated and is then resubmitted by the provider, what will occur?
Medical necessity denial
When this type of denial is received, it indicates the diagnosis code submitted with the procedure code does not meet coverage guidelines.
The health plan’s coverage determination
For medical necessity denials, reviewing this will assist in determining if charges should be appealed or written off
Modifier 58
Staged or Related Procedure or Service by the Same Physician or other Qualified Healthcare Professional
During the Postoperative Period
Modifier 59
Distinct Procedural Service
Modifier 78
Unplanned Return to the Operating/Procedure Room by the Same Physician or other Qualified
Healthcare Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
Modifier 79
Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period
For dates of service beginning September 1, United Healthcare will require the use of this modifier on Evaluation and Management (E/M) claims submitted by physicians on behalf of employed nurse practitioners, physician assistants, and clinical nurse specialists
1. An internal claims appeal process
2. Notice to enrollees of available internal and external appeals processes
3. Allowance for an enrollee to review their file and present evidence and testimony as part of the appeals process
4. An external review process

Per the ACA, the appeals process must
include at least these things
Part of Aetna’s appeals process, these are formal reviews of claims reimbursements if a provider believes he or she was paid at an incorrect rate or not according to contract
Within 180 calendar days of the initial claim decision
What is Aetna’s timeframe for submission of reconsiderations?
Within 60 calendar days of the previous decision
What is Aetna’s timeframe for submission of appeals?
1. Whether a claim was paid correctly (underpaid, paid to incorrect provider, etc.)
2. Whether the provider information and/or contract are set up correctly

Under its appeals process, United Healthcare will review these two things
Within twelve months of the date of the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA)
When must a claim reconsideration request be submitted for UHC?
A formal appeal request may be submitted
If a Claim Reconsideration is denied, what other option does a provider have?
Contacting Cigna HealthCare
For Cigna, many claims that have been denied due to claim processing errors or missing claim information can be resolved informally by doing this
Through single-level appeals
How are contractual disputes for denials and payment disputes resolved with Cigna?
180 calendar days
A single-level provider payment review must be initiated within this timeframe
from the date of the initial payment or denial decision from Cigna
After exhausting the internal appeals process with Cigna, what is the next option for providers?
90-day timely filing period for participating
providers, 180 days for out-of-network claim

What are Cigna’s timely filing periods for participating providers and out-of-network claims?

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