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If your H0015 / IOP claims are denying for CO-197 / No Prior Authorization, normally this code does not require auth, but H0015 TG/PHP does.
After working with a rep at Humana Healthy Horizons recently to help get issues resolved, It was communicated they had a system update in January that has created a glitch between these two codes and have since been denying claims that should not be denying.
The issue has been updated in their most recent CPSE report (Claims Payment System Error) that comes out on the 15th of each month.
This means that they are aware and working on the issue to get it fixed. (Supposedly)
The only option is to continue to submit these claims even though they will deny. When the system error has been fixed it will connect back to all of the claims that are connected to the CPSE and reprocess.
The Solution
It is good to keep a list with the claim information, but getting reimbursement may be tough with this issue, as these claims will not be paying in the meantime and will increase the denial rate of any facility taking this insurance.
A Closer Look at H0015 and Denial Code CO-197
The very ominous reference for denial of “CO-197” likely refers to the CO-197 denial code in medical and behavioral health billing, rather than a double agent from the Kingsman universe.
CO-197 Denial Code:
Meaning:
CO-197 indicates a claim denial due to the absence of required precertification, prior authorization, or notification before a medical service was rendered.
Reason: This denial happens, like many other denial codes, for multiple reasons. However, this is normally when healthcare providers fail to obtain the necessary approvals from insurance companies or payers before providing certain medical services.
Impact: CO-197 denials can lead to delayed payments, increased administrative burden, and potential revenue loss for healthcare providers.
And here are the multiple causes of CO-197 Denials, that you will need a dart and a dart board to keep trying to fix:
Lack of Pre-authorization: Failing to obtain prior approval for services requiring it.
Insufficient Documentation: Not providing documentation necessary to prove or meet the logistical requirements for medical necessity or justify the service.
Incorrect Coding: Using the wrong codes or not adhering to coding guidelines.
Failure to Track Authorization Status: Not monitoring pre-authorization requests, potentially leading to missed approvals.
Prevention and Resolution
- Understand Payer Requirements: Familiarize yourself with each insurance company’s pre-authorization policies and procedures.
- Obtain Pre- or Retro-authorization: Always secure the required pre-authorization before providing services that need it.
- Maintain Accurate Documentation: Keep detailed records to demonstrate medical necessity and support the services provided.
- Utilize Technology: Leverage electronic health records (EHR) and practice management (PM) systems to track pre-authorizations and streamline billing.
- Appeal Denials: If a denial occurs, review the denial notice, correct any errors, gather supporting documentation, and submit an appeal within the specified timeframe.
In essence, CO-197 is a denial code highlighting the importance of adhering to insurance company guidelines and obtaining necessary approvals before rendering medical services.
GOOD LUCK!!!
Orrrrrrrrr…. just call us 😉