Denial reasons
CO 18 – Duplicate claim/service
Corrected claim should be filed with the 4th digit of the bill type ‘7’.
How to Avoid Duplicate Claim Denials
- Check your remittance advice for previously posted claim
Verify reason initial claim was denied
Don’t just resubmit to correct a denial
Use the IVR or NGSConnex to check on current claim status
Allow 30 days from the receipt date
Make sure your billing service/clearinghouse is waiting the appropriate time frame
Detailed plan of action for working on duplicate claims.
Review the Initial Claim Submission: First, ascertain if the denial is valid. Sometimes, a claim may be incorrectly labeled as a duplicate. This could be due to errors in filling out the claim form, such as erroneously filling out Field 4 when claiming for one encounter. The last digit in this field indicates whether it’s an initial claim or a rebill. Therefore, ensure this field correctly reflects the nature of the claim.
Check for Communication Issues Within Your Team: If multiple individuals from your agency provide different services and attend the same meeting for/with a client, make sure they discuss who is billing for what service. This helps prevent situations where more than one person bills for the same time period, leading to duplicate claim denials.
Ensure Correct Coding and Modifier Combinations: Verify that your claim includes the correct rate code, procedure code, and modifier combinations. Inaccurate combinations can lead payers to view claims as duplicates erroneously.
Resubmitting or Appealing: If you find that the claim is not a true duplicate and it was denied due to an error on the payer’s part, you should resubmit the claim with the necessary corrections or appeal the decision. When resubmitting, indicate that it is a rebill (if applicable) by adjusting the last digit in Field 4 accordingly.
Follow-Up with Plans for Offsite Claims: If you are submitting offsite claims, ensure they are not being erroneously viewed as duplicative by discussing with the plans.
Resubmission of Previously Denied Telehealth Claims: If the duplicate denial pertains to telehealth claims denied due to the telehealth 95/GT modifier combination, these should have been reprocessed. In cases where previous denials occurred for this reason, do not resubmit but appeal, and only resubmit if a correction is required.
Using Modifiers Appropriately: If the service is unilateral (affecting only one side of the body), submit HCPCS Modifier RT or LT, as appropriate. For bilateral services (affecting both sides), submit CPT Modifier 50.
Indicating Multiple Services Separately: Use appropriate modifiers to indicate multiple services as separate for payment purposes. This helps clarify that the services are distinct and not duplicates.
Consolidating Services on One Claim: To prevent future duplicate service denials, consider submitting one claim with all lines that are administered for a claim on the same date of service. Submitting multiple claims for services on the same date may result in denials for duplication.
Ensure this is not rooted in erroneously filling out Field 4 of the claim (see billing.ctacny.org) when claiming for one encounter. The last digit indicates whether this is an initial claim (first time submitting for that encounter) or a rebill. If you are rebilling for a claim because you have not heard back from the MMCP, be sure to change the last digit in Field 4 to indicate this is a rebill.
This may be due to a lack of communication. Ensure people at your agency are not billing for the same time period, for example if 3 individuals who provide different services attend the same meeting for/with the client make sure they discuss who is billing.
Discuss with plans and ensure that offsite claims are not being erroneously viewed as duplicative. Ensure claim includes correct rate code, procedure code/ modifier combo combination so that systems do not erroneously view as duplicates
Analysis of Patterns of Duplicate Claims – From Medicare
The contractors shall establish a system for continuing analysis of duplicate claims. This includes the systematic evaluation of returned “Medicare Summary Notices” from beneficiaries and
communications from providers indicating a duplicate payment has been made, as well as returned checks from any payee.
The contractor’s system should provide for analyzing duplicate claim receipts to determine whether certain providers are responsible for duplicates and, if so, identify those providers. The contractor should educate such providers to reduce the number of duplicates they submit. Should those providers continue to submit duplicate claims, the MAC should initiate program integrity action.
Case Study:
A clinic repeatedly faced duplicate claim denials. They implemented a system where every claim submission was logged and tracked. The billing staff received training to use NGSConnex for checking the status of claims before making any new submissions. They also set alerts for claims that reached 30 days without a response. As a result, the clinic saw a significant reduction in duplicate claim denials, improved its billing efficiency, and avoided being flagged as an abusive biller. This case demonstrates the effectiveness of proactive monitoring and staff training in preventing duplicate claim denials.
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