Medical Claims Processing

For payment, status or attorneys inquiries:

Insurance Company

Phone Number

Endnotes

Aventus Insurance

844 776 4361 Option 5

Centry National Insurance

844 776 4361 Option 5

Frequently asked questions

Endnote 5 - The Evaluation and Management code used was repeated during the course of care. This high level of code is not usually performed more than once during the course of treatment.


Explanation: EN 5 denials are a DecisionPoint Analyst Edit flag used to alert the
adjuster that the documentation should be reviewed. If warranted, per the CPT guidelines an Evaluation and Management (E/M) service has criteria that must be
met and documented. Overriding to allow payment will be at Adjuster discretion.




Endnote 6 – Non Specific Diagnosis


Explanation: EN 6 denials are a DecisionPoint Analyst Edit flag used to alert the
adjuster that a review of medical records and/or billing may be warranted to
confirm actual procedure(s) performed or relatedness to the motor vehicle accident.

The Bill Specialist or the Adjuster can request the Provider to submit a more specific
diagnosis on a corrected claim and/or supporting documentation if not submitted
with the original claim.
If the Provider refused to submit any additional information this call will be referred
to the adjuster with a diary note placed in the claim referencing the conversation by
the Bill Specialist and payment consideration will be at Adjuster discretion.




Endnote 12 – Non-Specific Procedure - This CPT/HCPCS code is a "non-specific code". As noted in CPT/HCPCS a description of this procedure must accompany the bill for proper consideration of payment and for verification of proper coding


Explanation: EN12 denial is a DecisionPoint Analyst Edit flag used to alert the adjuster the procedure code submitted is not specific and a review of medical records and/or billing may be warranted to confirm actual procedure(s) performed or relatedness to the motor vehicle accident.
The Bill Specialist can request the documentation if it has not been submitted with the original claim for review by the Adjuster and payment consideration will be at Adjuster discretion.




Endnote 37 - Per Split- Extra units have been separated from the original line item.


Explanation: EN 37 is a DecisionPoint Analyst Edit flag used to alert the Adjuster that
additional units billed were separated because the units billed are more than normally expected per encounter.
The Bill Specialist or the Adjuster can request additional information if not submitted
with the original claim. These documents will be linked to the specific bill for adjuster review and payment consideration at the Adjuster discretion.




Endnote 41 - The amount allowed was reviewed using the FH RV Benchmark Database.


Explanation: Fair Health Benchmark pricing is available and optional in DecisionPoint
for non-fee schedule states. Utilizing this feature is at the Insurance Company Policy
Discretion. The adjuster should be educated by their Account Manager on handling
Provider disputes and balancing billing inquires.

The Bill Specialist will explain the claim was reduce per Fair Health benchmark data
and any question regarding the reduction will need to be addressed with the
adjuster. The Bill Specialist can offer the link if the question arises regarding the Fair Health pricing support.
Detailed Description: FAIR Health (www.fairhealthus.org), a non-profit organization
who maintains the only market based benchmark data in the industry today FAIR
Health utilizes a geographic breakdown called “geozips” whereby they have grouped
geographies together for purposes of collecting data. According to FAIR Health the
geozips are: “geographic areas, generally defined by the first three digits of a zip
code. Classifying charges by geozips ensures that the benchmarks are relevant to a
specific area”. An overview of FAIR Health’s benchmark data can be found at:
http://www.fairhealthus.org/DataSolution




Endnote 42 – By Report


Explanation: EN 42 is a DecisionPoint Analyst Edit flag used to alert the adjuster
that there is no Benchmark pricing for this service.

The Bill Specialist or the Adjuster can request additional information if not submitted
with the original claim. These documents will be linked to the specific bill for adjuster review and payment consideration.
If the Provider refused to submit any additional information this call will be referred to the Adjuster with a diary note placed in the claim referencing the conversation by the Bill Specialist and payment consideration will be at Adjuster discretion.




Endnote 67 - Surgical Map Mismatch


Explanation: The anesthesia service for this date does not match the surgical service
date and/or surgical procedure on record for this claimant. Please review the coding
of services for accuracy. A review of the medical records and/or billing may be
warranted to confirm actual procedure(s) performed. Review of the documentation
and ultimate decision for payment will be at the adjuster discretion.




Endnote 71 - Number of spinal/body regions within the diagnoses submitted by the Provider does not correlate to the number of regions as described in the procedure code(s) reported. Additional supporting clinical documentation is required to re-evaluate appropriate level of manipulation for reconsideration of payment.


5 Spinal Regions: Cervical Thoracic Lumbar Sacral Pelvic Explanation: DecisionPoint triggers the EN 71 denial because the level of the
Chiropractic Manipulative Treatment procedure codes submitted do not match the
spinal diagnosis codes submitted. Additional diagnosis of the level for the spine that
was manipulated is required to match the level of the Chiropractic Manipulative
Treatment code submitted. For example, 98941 represent 3-4 regions of the spine
but only the cervical diagnosis was submitted.
The Adjuster can request a corrected claim with additional diagnosis codes related to the spinal region.
If the Provider refused to submit any additional information this call will be referred
to the adjuster with a diary note placed in the claim referencing the conversation by
the Bill Specialist and payment consideration will be at Adjuster discretion.




Endnote 216 – Non-Covered Procedure/Service by Medicare


Explanation: Endnote 216 denials are related to Medicare pricing for Non-Covered
service. This endnote is a DP Analyst Edit flag used to alert the adjuster that these
procedures are not covered by Medicare. This information below is being provided
to assist you in any future decisions regarding EN 216 flag/denials.
The provision in Act 6 states that insurers should pay 80% of the Provider's billed
charge if no Medicare payment exists. This is currently what DecisionPoint will do
(allow at 80% with EN 28) when a code is not specified as non-covered and also does
not have an established fee. For codes that fall under the EN 216 functionality
(Medicare Status N codes = Non-Covered Services), customers will need to make a
business decision on whether or not to allow at 80% despite it being non-covered
under Medicare at Adjuster discretion.
https://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage




Endnote 318 - National Correct Coding Initiative(NCCI) Practitioner Denial –Superscript = 0


Explanation: According to CMS, there are no NCCI-associated modifiers that are
allowed with this code pairing and there are no circumstances in which both
procedures of the code pair should be paid the same beneficiary on the same date
of service by the same Provider.




319 – NCCI Practitioner Denial –Superscript = 1


Explanation: This line item has been flagged by the National Correct Coding Initiative
(NCCI) Practitioner edit database with a superscript of 1, which indicates that the
line item will be allowed when an appropriate NCCI modifier is present. This edit can
be reviewed at
http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage.

Endnote 318 and 319 are utilized in the states where Medicare billing guidelines are
applicable.





 

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