Denial code B7 and B9 -Provider was not eligible for this procedure

Q: We received a denial with claim adjustment reason code (CARC) CO/PR B7. What steps can we take to avoid this denial?
Provider was not certified/eligible to be paid for this procedure/service on this date of service.
A: This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, or when a procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or a laboratory service is missing a required modifier.
Submit claims for services rendered when the provider had active Medicare billing privileges.
Review the Medicare Remittance Advice (RA), and verify the date of service.
• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.
Note: The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.
• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification
 Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.

Q: We received a denial with claim adjustment reason code (CARC) PR B9. What steps can we take to avoid this denial?

Patient is enrolled in a hospice.
A: Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.
The following situations require a modifier be applied to the claim prior to submission.
• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
• Claim should be submitted with modifier GV.
• If claim was submitted with the GV modifier, check patient's file to verify that the attending physician is not employed by the hospice provider.
• Services not related to the hospice patient’s terminal condition:
• Claim should be submitted with modifier GW.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient's terminal condition.
• If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.

PR - Patient Responsibility denial code list

MCR - 835 Denial Code List  PR - Patient Responsibility

 We could bill the patient for this denial however please make sure that any other rejection reason not specified in the EOB.
Same denial code can be adjustment as well as patient responsibility. For example PR 45, We could bill patient but for CO 45, its a adjustment and we can't bill the patient.

PR 1 Deductible Amount Member’s plan deductible applied to the allowable benefit for the rendered service(s).
PR 2 Coinsurance Amount  Member’s plan coinsurance rate applied to allowable benefit for the rendered service(s).
PR 3 Co-payment Amount Copayment Member’s plan copayment applied to the allowable benefit for the rendered service(s).
PR 25 Payment denied. Your Stop loss deductible has not been met.
PR 26 Expenses incurred prior to coverage.
PR 27 Expenses incurred after coverage terminated.
PR 31 Claim denied as patient cannot be identified as our insured.
PR 32 Our records indicate that this dependent is not an eligible dependent as defined.
PR 33 Claim denied. Insured has no dependent coverage.
PR 34 Claim denied. Insured has no coverage for newborns.
PR 35 Lifetime benefit maximum has been reached.
PR 85 Interest amount. This change effective 1/1/2008: Patient Interest Adjustment (Use Only Group code PR)
PR 126 Deductible -- Major Medical
PR 127 Coinsurance -- Major Medical
PR 140 Patient/Insured health identification number and name do not match
.
PR 149 Lifetime benefit maximum has been reached for this service/benefit category.
PR 166 These services were submitted after this payers responsibility for processing claims under this plan ended.
PR 168 Payment denied as Service(s) have been considered under the patient's medical plan. Benefits are not available under this dental plan
PR 177 Payment denied because the patient has not met the required eligibility requirements
PR 200 Expenses incurred during lapse in coverage
PR 201 Workers Compensation case settled. Patient is responsible for amount of this claim/service through WC “Medicare set aside arrangement” or other agreement. (Use group code PR).
PR 204 This service/equipment/drug is not covered under the patient’s current benefit plan
PR B1 Non-covered visits.
PR B9 Services not covered because the patient is enrolled in a Hospice.

Here you could find Group code and denial reason too.
Adjustment  Group Code Description

CO Contractual Obligation
CR Corrections and Reversal
OA Other Adjustment
PI Payer Initiated Reductions
PR Patient Responsibility

UHC appeal claim submission address

Claim appeal Instruction

If you believe you were underpaid by us, the first step in resolving your concern is to submit a Claim Reconsideration as described above.

If you still do not agree with the outcome of the Claim Reconsideration decision in Step 1, you may submit a formal appeal request to:

UnitedHealthcare Provider Appeals
P.O. Box 30559
Salt Lake City, UT 84130-0575

For Empire Plan
UnitedHealthcare Empire Plan,
P.O. Box 1600
Kingston, NY 12402-1600
Level 1. Expedited Medical Review
UnitedHealthcare Central Escalation Unit
P.O. Box 30573
Salt Lake City, UT 84130-0573
Fax: 801-567-5498

Dental Issues Appeals/Grievance Coordinator Grievance & Appeals Department
P.O. Box 30569
Salt Lake City, UT 84130-0569 Fax: (714) 364-6266

Level 3: Expedited External, Independent Review
Physical Health Issues UnitedHealthcare Central Escalation
Unit 4316 Rice Lake Road
Duluth, MN 55811
Fax: 801-938-2100 or 801-938-2109

Your appeal must be submitted to us within twelve (12) months from the date of the adjustment decision shown on the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). Attach all supporting materials such as member specific treatment plans or clinical records to the formal appeal request, based on the reason for the request. Include information which supplements your prior adjustment submission that you wish to have included in the appeal review.
Our decision will be rendered based on the materials available at the time of formal appeal review.
If you are appealing a claim that was denied because filing was not timely:

1. Electronic claims – include confirmation that UnitedHealthcare or one of its affiliates received and accepted your claim.
2. Paper claims – include a copy of a screen print from your accounting software to show the date you submitted the claim.
Note: All proof of timely filing must also include documentation that the claim is for the correct patient and the correct visit.

If you are disputing a refund request, please send your letter of appeal to the address noted on the refund request letter. Your appeal must be received within thirty (30) calendar days of the date of the refund request letter, or as required by law or your participation agreement, in order to allow sufficient time for processing the appeal, and to avoid possible offset of the overpayment against future claim payments to you. When submitting the appeal, please attach a copy of the refund request letter and a detailed explanation of why you believe we have made the refund request in error.
If you disagree with the outcome of any claim appeal, or for any other dispute other than claim appeals, you may pursue dispute resolution as described in the Resolving disputes section and in your agreement with us. In the event that a member has authorized you to appeal a clinical or coverage determination on the member’s behalf, such an appeal will follow the process governing member appeals as outlined in the member’s benefit contract

Here You could find the UHC claim reconsideration form

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/UnitedHealthcare%20Request%20for%20Reconsideration%20Form/ClaimReconsiderationRequestForm.pdf

UnitedHealthcare Claim Reconsideration Request Form

Instructions: This form is to be completed by UnitedHealthcare – contracted physicians, hospitals or other health care professionals to request a claim reconsideration for members enrolled in commercial benefit plans administered by UnitedHealthcare and Medicare plans administered by SecureHorizons® and Evercare®.

Mail address: Send all Claim Reconsideration requests to the address on the back of the members identification card (ID), or the address on the EOB
or PRA. NOTE: If you are receiving the consolidated 835, you may verify the enrollee’s correspondence address using the eligibility search function on
UnitedHealthcareOnline.com.


Instructions for submitting Claim Reconsideration Requests

A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration Request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced.

This reference tool provides instruction regarding the submission of a Claim Reconsideration Request and details the supporting information required for claim reconsiderations or to correct claims, and explains those processes.

There are several ways to submit a Claim Reconsideration Request

1. Electronic Claim Reconsideration Request with attachments on Optum Cloud

For information on registering for access to the Optum Cloud Dashboard, see the Administrator Registration and Importing Users Quick Reference Guide.

By using this method, you can:

• Reduce the overall turnaround time for the request.
• Receive immediate confirmation and a unique tracking number to show we received your request.
• Check submission status throughout the process.

2. If you are a registered user on UnitedHealthcareOnline.com, use Electronic Claim Reconsideration for submissions without attachments.

By using this method:
• You will be notified that your request was received.

To learn more about submitting claim reconsiderations without attachments, you may view the step-by-step instructions in the Claim Reconsideration Quick Reference Guide.

3. To mail in paper Claim Reconsideration requests, complete the form below.

Where to send Claim Reconsideration Requests:

• For UnitedHealthcare and UnitedHealthcare West, if your Claim Reconsideration Request is for a Commercial or Medicare member, send the paper Claim Reconsideration Requests to one of the following:

* The address on the Explanation of Benefits (EOB) or the Provider Remittance Advice (PRA)

* The claim address on the back of the member’s ID card

• For UnitedHealthcare Empire Plan, send to:

P.O. Box 1600
Kingston, NY 12402-1600



Instructions for submitting Claim Reconsideration Requests

A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration Request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced.

This reference tool provides instruction regarding the submission of a Claim Reconsideration Request and details the supporting information required for claim reconsiderations or to correct claims, and explains those processes.

There are several ways to submit a Claim Reconsideration Request.

1. Electronic Claim Reconsideration Request with attachments on Optum Cloud

For information on registering for access to the Optum Cloud Dashboard, see the Administrator Registration and Importing Users Quick Reference Guide.

By using this method, you can:

• Reduce the overall turnaround time for the request.

• Receive immediate confirmation and a unique tracking number to show we received your request.

• Check submission status throughout the process.


2. If you are a registered user on UnitedHealthcareOnline.com, use Electronic Claim Reconsideration for submissions without attachments.

By using this method:

• You will be notified that your request was received.

To learn more about submitting claim reconsiderations without attachments, you may view the step-by-step instructions in the Claim Reconsideration Quick Reference Guide.

3. To mail in paper Claim Reconsideration requests, complete the form below.

Where to send Claim Reconsideration Requests:

• For UnitedHealthcare and UnitedHealthcare West, if your Claim Reconsideration Request is for a Commercial or Medicare member, send the paper Claim Reconsideration Requests to one of the following:


* The address on the Explanation of Benefits (EOB) or the Provider Remittance Advice (PRA)

* The claim address on the back of the member’s ID card

• For UnitedHealthcare Empire Plan, send to:

P.O. Box 1600

Kingston, NY 12402-1600

• For UnitedHealthcare Community Plan, if your Claim Reconsideration Request is for a Medicaid/Chip member, go to:

Community Plan Claim Reconsideration Mailing Addresses



NOTE:

• This reference guide should not accompany the paper Claim Reconsideration Request form you are submitting.

• No new claims should be submitted with the paper form.

• Do not use the paper form for formal claims appeals or disputes. When applicable, continue to follow your standard appeals process for formal appeals or disputes as found in your provider manual or agreement.




The following are the explanations of reasons for requesting a paper claim reconsideration

1. Previously denied as “Exceeds Timely Filing”

Timely filing is the time limit for filing claims, which is specified in the network contract, a state mandate or a benefit plan. For a non-network provider, the benefit plan would decide the timely filing limits. When timely filing denials are upheld, it is usually due to incomplete or invalid documentation submitted with Claim Reconsideration Requests.
Submission requirements for electronic claims:

* Submit an electronic data interchange (EDI) acceptance report. This must show that UnitedHealthcare or one of our affiliates received, accepted and/or acknowledged the claim submission.

* A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report.

• The acceptance report must indicate the claim was either “accepted,” “received” and/or “acknowledged” within the timely filing period.

Submission requirements for paper claims:

* Submit a screen shot from your accounting software that shows the date the claim was submitted. The screen shot must show the:

• Correct member name

• Correct date of service

• Submission date of claim that is within the timely filing period


2. Previously denied for “Additional Information”

Please attach a copy of all information requested and include the following information on the first page of the request:

* Patient name

* Patient's address

* Patient member ID number

* Provider name and address

* Reference number

Add the additional information requested. Examples include:

* Medical notes

* Anesthesia time units

* Current Procedural Technology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes (missing, illegible, or deleted)

* Date of service

* Description of service

* Diagnosis code where the primary code is missing, illegible or is the wrong number of digits

* Physician name

* Patient name

* Place of service (POS) code

* Provider's Tax Identification Number (TIN)

* Semi-private room rate

* Accident information





3. Previously denied for Coordination of Benefits information

Commercial Coordination of Benefits claim requirements

* Primary Payer Paid Amount – Submit the primary paid amount for each service line on the 835 Electronic Remittance Advice (835) or EOB. Submit the paid amount on institutional claims at the claim level.

* Adjustment Group Code – Submit the other payer claim adjustment group code found on the 835 or the EOB. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Reason Code – Submit the other payer claim adjustment reason code on the 835 or the EOB. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Amount – Submit the other payer adjustment monetary amount.

* Preference – Submit professional claims at the line level as allowed by the primary payer. Submit institutional claims at the claims or line level. The service level and claim level should be balanced. UnitedHealthcare follows 837p Health Care Claim Encounter – Professional (837p) and 837i Health Care Claim Encounter - Institutional (837i) guidelines.

Medicare Primary Coordination of Benefits claim requirements

* Adjustment Group Code – Submit the other payer claim adjustment group code on the 835 or the EOB. At the claim level, do not enter any amounts included at the line level. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Reason Code – Submit the other payer claim adjustment reason code on the 835 or the EOB. At the claim level, do not enter any amounts included at the line level. Common reasons for the other payer paying less than billed include: deductible, co-insurance, copayment, contractual obligations and/or non-covered services.

* Adjustment Amount – Submit the other payer adjustment amount.

* Medicare Paid Amount – Submit the other payer claim level and line level paid amounts when UnitedHealthcare is the secondary payer to Medicare.

* Medicare Approved Amount – Submit the other payer claim level and line level allowed amounts when UnitedHealthcare is the secondary payer to Medicare.

* Patient Responsibility Amount – Submit the monetary amount for which the patient is responsible from the 835 or the Medicare EOB.

* Medicare Acceptance of Assignment – Indicate whether the provider accepts the Medicare assignment.

* Preference – Submit professional claims at the line level if the primary payer provides the information, and submit institutional claims at either the line or claim level. The service level and claim level should be balanced. 



UnitedHealthcare follows 837p and 837i guidelines.

Medicaid Primary Coordination of Benefits Claims Requirements

Medicaid is the final payer in all coordination of benefits scenarios.






4. Resubmission of a corrected claim

Consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements, submit corrected claims in their entirety.

If a claim needs correction, please follow these guidelines:

* Make the necessary changes in your practice management system, so the corrections print on the amended claim.

* Attach the corrected claim (even line items that were previously paid correctly). Any partially-corrected request will be denied. Enter the words, “Corrected Claim” in the comments field on the claim form. Your practice management system help desk or your software vendor can provide specific instructions on where to enter this information in your system. If you do not have this feature, stamp or write “Corrected Claim” on the CMS 1500 form. Changes must be made in your practice management system and then printed on the claim form. You may not write on the claim itself.

* The resubmitted claim is compared to the original claim and all charges for that date of service. The provider and patient must be present on the claim, or we will send a letter advising that all charges for that day are required for reconsideration.

* Complete the Claim Reconsideration Request form as instructed and mark the box on Line 4 for Corrected Claims. Continue to the comments section and list the specific changes made and rationale or other supporting information.

UB04: UB Type of Bill should be used to identify the type of bill1 submitted as follows:

* XX5 Late Charges

* XX7 Corrected Claim

* XX8 Void/Cancel previous claim

5. Previously processed but rate applied incorrectly resulting in over/underpayment

Network Providers - Please check your fee schedules prior to submitting a claim reconsideration request for this reason. Indicate the contract amount expected by code or case rate, compared to the amount received, as well as other factors related to the over- or under-payment. If you disagree with the fee schedule your claim was paid by, contact your Network Management Representative. Go to and select your state to find the appropriate network management contact for your area.

6. Resubmission of Prior Notification/Prior Authorization Information

Submit a prior authorization number and other documents that support your request. If you spoke to a customer service representative and were told that notification was not required, please submit the date, time and reference number of that call and the name of the representative handling the call. Please also advise if the service was performed on an emergency basis and therefore notification was not possible.

7. Resubmission of a claim with bundled services

Review your claim for appropriate code billing, including modifiers. If the claim needs to be corrected, please submit a corrected claim. If a bundled claim is not paid correctly, submit a detailed explanation including any pertinent information on why the bundling is incorrect.

8. Other (Provide any additional information that supports your request)


UnitedHealthcare Single Paper Claim Reconsideration Request Form

This form is to be completed by physicians, hospitals or other health care professionals for paper Claim Reconsideration Requests for our members.

• Please submit a separate claim reconsideration request form for each request.

• No new claims should be submitted with this form.

• Do not use this form for formal appeals or disputes. Continue to use your standard appeals process for formal appeals or disputes.

Please refer to the attached Claim Reconsideration Reference Guide, your provider administrative manual or our provider website for additional details including where to send paper Claim Reconsideration Requests. You may verify the member’s address using the eligibility search function on the website listed on the member’s health care ID card.