Overview

The Denial Code page is used to manage the adjustment and denial rules that determine the behavior of group and reason codes used in Connect Back Office. Use the Denial Code page to add or modify user-defined rules that are associated to the HIPAA-compliant reason and group codes, to define a statement label, to assign it to a denial code group, or to inactivate a system adjustment and denial rule.

The adjustment and denial rule determines how financial responsibility roll to, adjustments, and contractual writeoffs are handled for group and reason codes.

The Denial Code page is divided into two tabs:

  • Primary
  • Non-Primary

The Primary tab is used to define adjustment and denial rules for primary payments.

The Non-Primary tab is used to define adjustment and denial rules for non-primary (secondary) payments.

How to Get Here?

To open the Denial Code page for a new denial code:

From the Home Page:From the Menus:Via Shortcut Keys: 
  1. Click Denial Management from the Admin list.
  2. Click Create.
  1. Open the Admin menu and select Denial Management.
  2. Click Create.
  • From the Denial Management page, press [Alt] + [C].

To open the Denial Code tab for an existing denial code:

From the Home Page:
From the Menus:
Via Shortcut Keys: 
  1. Click Denial Management from the Admin list.
  2. Select the denial code to be modified.
  3. Click Update*.
  4. Click the Non-Primary tab, if needed.

*Alternate Navigation: Double-click the denial code from the list.

  1. Open the Admin menu and select Denial Management.

  2. Select the denial code to be modified.
  3. Click Update*.
  4. Click the Non-Primary tab, if needed.

*Alternate Navigation: Double-click the denial code from the list.

  1. From the Denial Management page, select the denial code to be modified.
  2. Press [Alt] + [U].
  3. Click the Non-Primary tab, if needed.

 

(Click an image below to enlarge.)

Denial Code: New Page / Primary Tab


Denial Code: New Page / Non-Primary Tab


Denial Code: [name] Page / Primary Tab

Denial Code: [name] Page / Non-Primary Tab

 

Field Definitions

Primary Tab

Field

Type

Required 

Description

General Section   
Code Free TextYes

The 1 to 10-character transaction code that identifies the adjustment and denial rule associated with the adjustment reason and denial codes used by payers to inform members why a claim was adjusted or denied. You cannot change the code on a system adjustment and denial rule.

Adjustment and denial rules determine the behavior of the group and reason codes that payers use to explain why a claim was not paid and the action that was taken, adjustment or contractual writeoff. The group and reason codes are HIPPA compliant and are specific to electronic claim filing. These codes are essential to the payment entry function for processing secondary claims correctly.

Adjustment and denial rules can be defined for the plan, payer, or practice. The adjustment and denial rule assigned to the practice are used as the default adjustment and denial rules for all payers and plans. The adjustment and denial rule assigned to a plan overrides the payer and the practice. The adjustment and denial rule assigned at the payer overrides those assigned to the practice.

InactiveCheckboxYes

Indicates the status of the adjustment and denial rule. By default, this option is set to No.

  • No - The adjustment and denial rule is currently active.
  • Yes - The adjustment and denial rule is no longer active, but is still listed on the Denial Management page. The adjustment and denial rule will not be applied in Connect Back Office.
DescriptionFree TextYes

The description of the adjustment and denial rule. 

You cannot change the description of a system adjustment and denial rule.
Statement LabelFree TextNo

Text that appears on the statement when the adjustment and denial rule is used in Connect Back Office.

Adjustment Drop DownYes 

Indicates whether an adjustment is allowed or disallowed when the adjustment and denial rule is applied in Connect Back Office. By default, this option is set to Allowed.

  • Allowed - An adjustment is allowed.
  • Disallowed - An adjustment is not allowed.
Writeoff Drop DownYes

Indicates whether a contractual writeoff is allowed or disallowed when the adjustment and denial rule is applied in Connect Back Office. By default, this option is set to Allowed.

  • Allowed - A contractual writeoff is allowed.
  • Disallowed - A contractual writeoff is not allowed.
Roll ToDrop DownYes 

The rule for rolling financial responsibility when this adjustment and denial rule is used in Connect Back Office. Select one of the following options to specify the next party who is responsible for paying the claim:

  • Next Plan - The financial responsibility rolls to the next payer in line. For example, if the claim has a primary and a secondary payer, and the primary payer adjusts or denies all or a portion of the claim, the financial responsibility will roll to the secondary payer. Note: If no secondary insurance exists, next plan rolls the balance to the guarantor.
  • Guarantor - The financial responsibility rolls to the guarantor.
  • Do Nothing - The financial responsibility remains as is and does not roll to another party.

When multiple group and reason codes have different adjustment and denial rules, the most conservative roll to rule is used. For example, suppose a payer uses two group and reason codes to adjust the payment amount on a claim. One group and reason code has an adjustment and denial rule with the Roll To rule of Next Plan and the other group and reason code has an adjustment and denial rule with a Roll To rule of Do Nothing. The adjustment and denial rule with the Roll To rule of Do Nothing will be applied to the payment because it is the most conservative rule. You can override this rule at the time of payment entry or in the guarantor account, where responsibility can be reassigned via Roll To in Active AR.

Denial Code GroupDrop DownNoThe name of the denial code grouping assigned to the adjustment and denial rule. The list of drop down options is pulled from the Denial Management / Denial Code Groups tab.
Exclude from Denial Code ReportsCheckboxNoIf checked, any denials associated with the denial code will not be included in any denial code reports, e.g., Insurance Payment Denial Detail report.
Group/Reason Codes Section  

The group and reason codes associated to the adjustment and denial rule for communicating from one payer to another as to why an adjustment or write-off is being taken. For example, PR (Patient Responsibility) is a group code that can have a reason code of 1, indicating that the amount of the adjustment is due to a deductible requirement.

The group and reason codes are used in the Claim Adjustment Reason Codes option in payment entry of Connect Back Office.

Group Code 

Display Only

(Pulled from created/updated Group/Reason Code.)

Yes

Associated to the adjustment or writeoff that is being applied to the claim by the payer. The following options are available:

Group CodeDescription
COContractual Writeoff
CRCorrection or Reversal
OAOther Adjustment
PIPayer Initiated Reduction
PRPatient Responsibility
Reason Code 

Display Only

(Pulled from created/updated Group/Reason Code.)

YesIdentifies the claim adjustment. The CSMA code associated with the group code, indicating the reason the claim is being adjusted or denied by the payer. This HIPAA group and reason codes are specific to electronic claims and communicate from one payer to another the reason the claim was not paid as it was billed. If the claim is being adjusted, the reason code is provided on the EOB or remittance advice.
Assignment Section   
Denial Code LevelDrop DownYes

These options determine the level to which the adjustment and denial rule is assigned: practice, payer, or plan. This information is required. By default, this option is set to Practice.

Adjustment and denial rules are assigned hierarchically by practice, payer, or plan. Payer and plan adjustment and denial rules override adjustment and denial rules at the practice, and the adjustment and denial rules at the plan override the adjustment and denial rules at the payer.

  • Practice - By default, this option is selected. The adjustment and denial rules assigned to the practice are used as the default adjustment and denial rules for all payers and plans. If you select this option, select the appropriate practice(s) from the Practice list.
  • Payer - This option specifies that the adjustment and denial rule is assigned to a specific payer. A payer adjustment and denial rule overrides the practice adjustment and denial rule. If you select this option, select the appropriate payer(s) from the Payer list.
  • Plan - This option specifies that the denial code is assigned to a specific plan. A plan denial code overrides the payer and practice denial codes. If you select this option, select the appropriate plan from the Plan(s) list.

 

Non-Primary Tab

The Non-Primary tab is used to define the adjustment and denial rule for the non-primary payment. It is a copy of Primary tab content, but can be updated as needed for the non-primary payment.

Field

Type

Required 

Description

Override Primary RulesCheckboxNoIf checked, the Non-Primary tab, and associated rule, is enabled. If enabled, the non-primary rule is applied to non-primary payments. If not checked, the Primary tab rule is applied to all payments, primary and secondary.
General Section   
Code Free TextYes

The 1 to 10-character transaction code that identifies the adjustment and denial rule.

The field cannot be edited on the Non-Primary tab.
InactiveCheckboxYes

Indicates the status of the adjustment and denial rule.

The field cannot be edited on the Non-Primary tab.
DescriptionFree TextYes

The description of the adjustment and denial rule. 

You cannot change the description of a system adjustment and denial rule.
Statement LabelFree TextNo

Text that appears on the statement when the adjustment and denial rule is used in Connect Back Office.

Adjustment Drop DownYes 

Indicates whether an adjustment is allowed or disallowed when the adjustment and denial rule is applied in Connect Back Office. By default, this option is set to Allowed.

  • Allowed - An adjustment is allowed.
  • Disallowed - An adjustment is not allowed.
Writeoff Drop DownYes

Contractual writeoffs are not allowed for non-primary payments.

The field is not enabled on the Non-Primary tab.
Roll ToDrop DownYes 

The rule for rolling financial responsibility when this adjustment and denial rule is used in Connect Back Office. Select one of the following options to specify the next party who is responsible for paying the claim:

  • Next Plan - The financial responsibility rolls to the next payer in line. For example, if the claim has a primary and a secondary payer and the primary payer adjusts or denies all or a portion of the claim, the financial responsibility will roll to the secondary payer. Note: If no secondary insurance exists, next plan rolls the balance to the guarantor.
  • Guarantor - The financial responsibility rolls to the guarantor.
  • Do Nothing - The financial responsibility remains as is and does not roll to another party.

When multiple group and reason codes have different adjustment and denial rules, the most conservative roll to rule is used. For example, suppose a payer uses two group and reason codes to adjust the payment amount on a claim. One group and reason code has an adjustment and denial rule with the Roll To rule of Next Plan and the other group and reason code has an adjustment and denial rule with a Roll To rule of Do Nothing. The adjustment and denial rule with the Roll To rule of Do Nothing will be applied to the payment because it is the most conservative rule. You can override this rule at the time of payment entry or in the guarantor account, where responsibility can be reassigned via Roll To in Active AR.

Denial Code GroupDrop DownNo

The name of the denial code grouping assigned to the adjustment and denial rule.

The field cannot be edited on the Non-Primary tab.
Exclude from Denial Code ReportsCheckboxNo

If checked, any denials associated with the denial code will not be included in any denial code reports.

The field cannot be edited on the Non-Primary tab.
Group/Reason Codes Section  

The group and reason codes associated to the adjustment and denial rule for communicating from one payer to another as to why an adjustment or write-off is being taken. For example, PR (Patient Responsibility) is a group code that can have a reason code of 1, indicating that the amount of the adjustment is due to a deductible requirement.

The group and reason codes are used in the Claim Adjustment Reason Codes option in payment entry of Connect Back Office.

Group Code 

Display Only

(Pulled from created/updated Group/Reason Code.)

Yes

Associated to the adjustment or writeoff that is being applied to the claim by the payer. The following options are available:

Group CodeDescription
COContractual Writeoff
CRCorrection or Reversal
OAOther Adjustment
PIPayer Initiated Reduction
PRPatient Responsibility

The table cannot be edited on the Non-Primary tab.

Reason Code 

Display Only

(Pulled from created/updated Group/Reason Code.)

Yes

Identifies the claim adjustment. The CSMA code associated with the group code, indicating the reason the claim is being adjusted or denied by the payer. This HIPAA group and reason codes are specific to electronic claims and communicate from one payer to another the reason the claim was not paid as it was billed. If the claim is being adjusted, the reason code is provided on the EOB or remittance advice.

The table cannot be edited on the Non-Primary tab.
Assignment Section   
Denial Code LevelDrop DownYes

These options determine the level to which the adjustment and denial rule is assigned: practice, payer, or plan.

The selection cannot be edited on the Non-Primary tab.

Adjustment and denial rules are assigned hierarchically by practice, payer, or plan. Payer and plan adjustment and denial rules override adjustment and denial rules at the practice, and the adjustment and denial rules at the plan override the adjustment and denial rules at the payer.

  • Practice - By default, this option is selected. The adjustment and denial rules assigned to the practice are used as the default adjustment and denial rules for all payers and plans. If you select this option, select the appropriate practice(s) from the Practice list.
  • Payer - This option specifies that the adjustment and denial rule is assigned to a specific payer. A payer adjustment and denial rule overrides the practice adjustment and denial rule. If you select this option, select the appropriate payer(s) from the Payer list.
  • Plan - This option specifies that the denial code is assigned to a specific plan. A plan denial code overrides the payer and practice denial codes. If you select this option, select the appropriate plan from the Plan(s) list.

Button Descriptions

Button

Shortcut Keys

Description

Step-By-Step Guides

Add[Alt] + [D]To add a group and reason code.
  1. From the Denial Code / Primary tab, click Add in the Group / Reason Codes section. The Add Group/Reason Code window opens.
  2. Open the Group Code drop down list and select a group code.
  3. Open the Reason Code drop down list and select a reason code.
  4. Click Save or Save & Add Next to add another one.
Remove[Alt] + [R]To delete a group and reason code.
  1. From the Denial Code / Primary tab, select the group/reason code to be removed from the Group / Reason Codes section.
  2. Click Remove. The line item is removed from the table.
Select All/None Provides a convenient way to associate/disassociate all records for the selected Denial Code Level. The button toggles between values upon selection. 

 

 

 

 

 

Related Topics

Denial Management

Denial Management / Denial Codes Tab

Denial Management / Denial Code Groups Tab

Creating Denial Management Rules

Updating Denial Management Rules

Deleting Denial Management Rules

 

 

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