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Action Codes for Medical Billing Processes

This document lists various action codes used for rebilling and adjusting claims, including codes for rebilling with edits, changing payor class, appealing denials, writing off balances, and billing secondary payors or patients. It provides guidance on when different action codes should be used based on factors like timely filing limits, payment status, and common billing issues. Non-workable claims are defined as those with zero balances, recently billed within 15-30 days, or with invalid patient information. The document also covers billing workflows for specific issues like workers compensation, appeals, deliveries and surgeries.

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R THARUN
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112 views3 pages

Action Codes for Medical Billing Processes

This document lists various action codes used for rebilling and adjusting claims, including codes for rebilling with edits, changing payor class, appealing denials, writing off balances, and billing secondary payors or patients. It provides guidance on when different action codes should be used based on factors like timely filing limits, payment status, and common billing issues. Non-workable claims are defined as those with zero balances, recently billed within 15-30 days, or with invalid patient information. The document also covers billing workflows for specific issues like workers compensation, appeals, deliveries and surgeries.

Uploaded by

R THARUN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Action Codes

504 - Rebill by editing Patient(primary)

505 - Rebill pay class(primary)

513 - Rebill without changing anything NCOF(primary)

525 Bill to (Secondary) in Electronic format.

893- Bill to (Secondary) in Paper format.

863 - Appeal with MR

572 write off (adjustment)

575 Credentialling issue with MCD &HMO of Medicaid plan

895 BTP when pr is OON for Commercial

898 BTP when pt have no Insurance -OR 21 not having any active Insurance

571-BTP when pt have active Insuranc & Balance need to Bill Patient

EX: Deductable, Balance (PTR), exhausted

Non-workable claims:
* Zero balance

* Recently billed-

For electronic -15-30 days, For paper- 30-45 days Recently worked work date in D screen D screen
shows with in 30 days

* Invalid Pt Info -: If pt's info is invalid (DOB, POL ID#, Name, Zip Code) then check face Sheet in
lyra/Ebridge to get correct info

If not found then BTP.

check Lyka / Ebridge & correct info we 504 action code.

I enter TX (respective Insurance pay class Enter Generate Insurance form y (enter) >504 action Code

Paper Submission Secondary :If sec don't allow electronic Claims, send via paper, send via with primary
EOB

→ we have 2 kind of Secondary Submission 525 and 893.

How to check ins accept paper &Electronic

*Utility files (3) > 6 enter > enter pay class check in block no 28 block 28 have y – electronic

12 screen → line # -> TX (XXXX)→N→ 504 Action code

worker Compensation: (Always primary) (513 Only paper claims. (Action - Only paper claims)

Diagnosis codes will starts with S/Z/O—Workers Compenstation


primary starts with “S”

LMP date → Onset date → RAI -508 Action Code they will update in Lyra (AI)

Appeals(863) 365 -DOS - Write of request 873 (Action Code)

with in ATFL - with in 10days RAI (508)

Passed ATFL - WOR→ 873

59409, 59490 - Delivery

59415,59414-> Surgeon

Encoder Pro (NCCI). follow LCD/NCD/CMS

520- Requesting to post paymentsit having EOB

903- Non workable (check Encashed' by incorrect Address).

PA claim

21005

Paid date is > 45 days AC is(882)

Paid date is < 45 days AC is 860

If we have Paid EOB AC is 520 (Check from paid date)

To adjust in deductable

• XXXX99. Amount 800 MSG →1(Deductable, CO-Pay, CO-Insurance) (Pri 574, SEC 525)

507- Set back for Reprocess &Review.

Billed Pt

1. 1° proceed Claim & PTR 1002, 571

2. PT have no active Insu- 1000; 898

3. 1 Insu should not be altered to self pay if the pt's policy is inactive for DOS

4. Rather, we should be updating 1002 in 2° column & transfer the amt to 1002.

6. Changing billing cycle 25 to 1& 26 to 2

5. This should be followed by all cases & Sheels 829

898-1> tx 1000> 898 (No active Ins)

571 – 1 denied as non covered PTR, Ded. (1>TX 1002 >571)

895 - if Commercial payer denial as provider non par, hold fol 120days after that BTP

Corrected Claim → Need to update resub Code 7 on block 22

Need to update claim # in block 14 in I screen & generate to claim

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