Your hospital has just received a reimbursement rejection from the fiscal intermediary for two outpatient procedures that were performed on the same day. This rejection was probably generated by
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CCI outpatient code editor
the billing system of the fiscal intermediary.
To understand the specific reason for the reimbursement rejection, you will need to review the rejection notice or explanation of benefits (EOB) provided by the fiscal intermediary. This document typically includes detailed information regarding the rejected claim, such as the reason for denial and any applicable denial codes or messages.
Here are the steps you can take to further investigate the rejection:
1. Identify the rejection notice: Look for any communication received from the fiscal intermediary regarding the rejected claim. This could be in the form of an electronic remittance advice (ERA), paper EOB, or a denial letter.
2. Review the rejection reason: Once you have the rejection notice, carefully read through it to understand the reason for denial. Common reasons for rejections related to outpatient procedures can include coding errors, lack of medical necessity, duplicate claims, or billing incomplete or incorrect information.
3. Look for denial codes or messages: The rejection notice may include specific denial codes or messages, which can provide more insight into the reason for denial. Denial codes are standardized codes used in the healthcare industry to identify specific reasons for claim denials.
4. Research the denial reason: If the rejection notice does not provide sufficient information, you may need to further research the specific denial reason. This can be done by referring to resources such as the fiscal intermediary's website, billing manuals, or contacting their provider relations department for clarification.
5. Take corrective action: Once you have identified the reason for denial, you can take appropriate corrective actions. This may involve resubmitting the claim with corrected information, appealing the denial if you believe it was incorrect, or initiating any necessary communication with the fiscal intermediary to address the issue.
It's important to note that the specific process and requirements for handling reimbursement rejections may vary depending on the healthcare system, payer, and country you are operating in. Consulting with your hospital's billing department or revenue cycle management team can provide more specific guidance for addressing reimbursement rejections.