PR22: Adjusted payment

PR22

Accounting for 2.1 percent of Medicare denials, No. 11 on the list is PR22: Payment adjusted because this care may be covered by another payer per coordination of benefits.

Here are three of the reasons providers might receive this denial:

1. The provider billed Medicare as the secondary payer and failed to attach the primary EOB, either electronically or hard copy.
2. The claim was billed to Medicare as the primary payer, but there is actually a commercial payer that is primary. In this situation, the provider would bill that commercial payer first and then bill Medicare as secondary.
3. There are issues with coordination of benefits where both Medicare and the commercial payer are showing that they are secondary. To straighten out this situation, the patient must call both insurances to determine which is primary and which is secondary before the provider is able to bill either one.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. She can be contacted at 419/448-5332 or [email protected].

Based on analysis of 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.