CO16 Denial on EOB

Note: This information was originally sent to clients in an email dated January 18, 2012. Since that time, a client sent the clarifying information in green, and more information was subsequently added shown in red below.

Clients sending in 5010 format to either Medicare or their clearinghouse are getting the following denial on their EOB. This edit is related to the new 5010 edits: 

CO 16 -n285 n286

Where:

16 = Claim/service lacks information which is need for adjudication.

285 = Missing/incomplete/invalid referring provider name.

286 = Missing/incomplete/invalid referring provider primary identifier.

Please Note: “Referring Physician" (Box 17 of the HCFA) should ALSO be called the "Ordering Physician". In other words, “Referring/Ordering Physician” is the Physician that establishes Medical Necessity. Therefore, when billing for a clinic or your own physician-directeddiagnostic studies, labs, and procedures, it is the "ordering" physician that goes in Box 17. The ordering physician could also be the billing or treating physician. In short, a “referral” is NOT necessarily an outside physician who sent the patient for treatment, although it could be.

In 4010, the Referring Provider was allowed on all claims transmitted. The program sent the information based on the Utility/Set Up /Parameter File and then 'automatically' sent the Referring Provider's information. However, in the 5010 format, the Referring Provider information is ONLY required on certain services, therefore, the program is no longer 'automatically' sending the Referring information.

To correct this edit, both Intellect and Unix clients will need to do the following: 

·         Add ALL rendering providers to the Utility/Referring file and complete the <Name>, <Doctor/Other = D>, and <NPI> fields. BUT, if the Utility/Insurance <Taxonomy> field is set to Y for any insurances, complete that field too. Blue Shield requires the Taxonomy.
We no longer use the <UPIN>, <Provider Number>, <State Lic>, <Commercial>, <Blue ShieldTax ID> fields, etc. from the referring in 5010 Elec billing. Only the NPI. Paper billing may still use some.  

·        Go to Charges/Modify and add the 'newly-added' Referring Provider to the charges.

Intellect (Windows):

1. Go to Charges/Modify.

2. Type in the account number and press [Enter].  

3. Enter the 'From' and 'To' dates of service and press [Enter]. 

4. Click on the appropriate date of service in the Date column, and type the letter 'M' in the Command column (C).

5. Tab to the Rdr (Referring Provider) field, type in the code that is appropriate for the charge as set up in Utility/Referring for the appropriate Provider, and press [Enter].

6. With the cursor in the Command column, type 'X' to exit.

7. Rebill.  

OnStaff 2000 (Unix):  

1. Go to Charges/Modify.

2. Type in the account number and press [Enter].

3. Enter the 'From' and 'To' dates of service and press [Enter].

4. Use the down arrow key to move to the appropriate Charge line.  

5. With the cursor in the Command column (C), type the letter 'M' (for modify).

6. Press [Enter] or tab to the Rdr (Referring Provider) field and type in the code that is appropriate for the charge as set up in Utility/Referring for the appropriate Provider.

7. Press the [Enter] key until the cursor is back to the Date column.

8. Press the Up arrow key and then type 'X'.

9. Press the [Enter] key or use the Down arrow key to get to 'Referring Code' field.

10. Type the same code as entered in step 6 and then use the [Enter] key or Down arrow key through to the end.  

11. Exit and rebill.   

Denied claims will then need to be re-billed.