Académique Documents
Professionnel Documents
Culture Documents
IN AND OUT OF
NETWORK
STEPHANIE THOMAS CPC, CANPC
OBJECTIVES
• Clearinghouse edits:
• Also called “exclusions” “clearinghouse rejected”
• Denials
• EOB denials, ERA reports
FRONT END DENIALS
1. Demographic info
2. Internal coverage dates (ex policy termed 8/31)
3. Authorization info
4. NDC and quantity
5. Referral, referring NPI
6. General coding guidelines
7. ICD10 verification
CLEARINGHOUSE DENIALS
• CO-234 Procedure not paid separately, CO-97 benefit included in another adjudicated
service
✓ Check NCCI edits and plan guidelines. Add modifier if appropriate
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