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MMO’s Most Common Denial Reasons:What You Can Do

Listed below are Medical Mutual of Ohio’s top five reasons for reimbursement denials, according to information provided to the OSMA by MMO. They are listed in descending order, beginning with the most frequent reason for denial. The OSMA is seeking this type of information from all major Ohio insurers in order to help practices become more cognizant of denial reasons. Below each denial is practical information regarding the steps you can take to avoid these denials.

Claim is a duplicate – Many practices when they are not certain if MMO has received their claim, resubmit it. Once the original claim gets adjudicated then any duplicates will be denied. While some practices use resubmission as a strategy to make sure all claims are received by MMO, there is a better and cheaper way to achieve this.

What to do: Remember that when you submit a claim it goes from your practice management system to your clearinghouse, and then from your clearinghouse to Emdeon, which serves as MMO’s clearinghouse, and then on to MMO. The claim submission pipeline could break down anywhere along the way. What is important to you is whether MMO has received it and is going to pay it. If you file your claims electronically, you should review the claims received report sent from Emdeon to your clearinghouse vendor, as this report will advise you if the claim was received by MMO. If the report indicates that the claim was received by MMO, use Emdeon Office or contact MMO’s Provider Inquiry Unit at (800) 362-1279 to check claim status.

If you suspect that MMO is not receiving your claims despite what the claims received report indicates, contact your clearinghouse to verify the reports accuracy. If you require further assistance, contact Emdeon to resolve the issue. If Emdeon cannot resolve the issue to your satisfaction, contact the Provider Inquiry Unit or your local MMO contracting representative. This saves you any additional claim submission fees (for example, from your clearinghouse) and saves staff time having to account for denied duplicate claims.

Finally, if you have reason to believe that any payer’s denials may constitute a pattern of practice by the company, please contact the OSMA’s payer relations staff. Remember, you would need to have solid documentation to support this assertion, as this is a very serious charge that insurance companies take pains to guard against.

Claim will not be processed until information regarding the patient’s treatment history is received – In other words, MMO has sent a request for additional information regarding a patient’s medical history and will not process this claim until it receives the requested information. The information could be requested from either the patient or the medical practice.

What to do: If MMO has requested medical history information from your practice, it is important to return the completed information as quickly as possible. This clears the way for you to submit claims on behalf of this patient. The OSMA’s position on this type of denial is that this is an issue between the patient and the insurance company and physician claims should not be held up as a result. The OSMA is currently discussing our position with payer representatives.

An Explanation of Medical Benefits (EOMB) is needed in order for secondary benefits to be considered – This denial happens often when Medicare is the primary payer and MMO is the secondary payer. The practice simultaneously sends a claim to Medicare and MMO. MMO will deny the claim because the primary payer has not processed its portion and the proper crossover of the claim has not taken place.

What to do: This is one of the easier fixes. If you file the claim with Medicare and include all of the proper crossover information for MMO as the secondary payer, then all you have to do is wait for Palmetto (Medicare) to process the claim. After Palmetto processes the claim , it will automatically be sent to MMO for processing and you should receive your secondary payment. If you try to file the secondary claim directly with MMO and it does not have the associated EOMB from Palmetto, then MMO will deny the claim. If you haven’t received payment on the secondary claim 30 days after you receive the EOMB from the primary payer, then it’s time to check into the status of the claim.

Patient not eligible – This type of denial is becoming more frequent among all insurance companies. As more Americans lose their health insurance, patients may knowingly or unknowingly present an outdated insurance card to the practice. The problem is that if you assume that the patient has coverage and you bill that insurance company, it may take you 30 days or more to find out from the insurance company that the patient does not have coverage. A month later, it’s much harder to collect your charges from the patient.

What to do: In today’s business environment, you must know how you are going to receive payment for the service before you provide the service. When the patient hands you an insurance card at check-in, you need to verify that the patient does indeed have coverage. If the patient does not have the necessary coverage, then its time to have a conversation with the patient about how they are going to pay for the service. For MMO patients, you can check eligibility using Emdeon Office, a service available to all MMO network physicians. If you wish to use Emdeon Office for Medical Mutual information only, a no-cost solution is available to Medical Mutual’s Network physicians. Visit the Provider section of MedMutual.com for more details. To use Emdeon Office as all-payer solution, you can register through MMO’s web site or call (877) 469-3263. Additionally, MMO’s VoiceConnect (Voice Response Unit) is available 24 hours a day, 7 days a week at (800) 362-1279. During regular business hours, representatives in the Provider Inquiry Unit are also available to speak with physicians.

Additional information is needed on the claim – In these cases, vital information was omitted on the submitted claim. The most common pieces of information missing from a claim receiving a denial of this kind are: 1) date of accident; 2) date of medical emergency; 3) date of onset.

What to do: The physician is advised to submit a corrected claim with the missing information. If the physician needs guidance as to what information is missing, service representatives at MMO’s Provider Inquiry Unit are available at (800) 362-1279 during normal business hours. Additionally, MMO encourages physicians to reference the Claims Submission section of the Professional Provider Manual (PPM). MMO’s PPM, with full keyword search capability, is available online in the Provider section of MedMutual.com under Tools and Resources.

The denial reasons listed above occur when a claim cannot be adjudicated. When payment is denied because the patient does not have a covered benefit for the service provided, the claim was adjudicated by MMO but your Notice of Payment will advise you that MMO is not responsible for the reimbursement of those services and the money owed will show as patient liability. This highlights the importance of verifying benefits prior to providing service. The patient may have a MMO insurance package, but the service or procedure that you are about to provide might not be covered by the policy. Check the patient’s coverage using Emdeon Office or use MMO’s VoiceConnect (Voice Response Unit) at (800) 362-1279.