The CO 16 denial code reason is used when a claim or service lacks the necessary information for processing. This may involve missing, invalid, or incorrect details. The healthcare provider is responsible for providing the missing information, and patients should not be billed for these claims. Additional information regarding the denial can be found in remark codes on the remittance advice. Providers should contact the insurance company before resubmitting the claim if further clarification is needed.
Here are some of the main reason for CO 16 denial code and their solutions:
Patient Demographics:
- MA27: The entitlement number or name on the claim is missing, incomplete, or invalid.
- MA36: The patient’s name is missing or incomplete.
- MA61: The Social Security number (SSN) is missing, incomplete, or invalid.
- N382: The patient identifier is missing, incomplete, or invalid.
Solution: Review the insurance card, verify eligibility, and enter the correct information on the claim form.
Billing Entity/Provider:
- N256: The billing provider/supplier name is missing, incomplete, or invalid.
- N257: The billing provider/supplier primary identifier is missing, incomplete, or invalid.
- N258: The billing provider/supplier address is missing, incomplete, or invalid.
- MA112: Group practice information is missing, incomplete, or invalid.
Solution: Enter the correct billing provider/supplier information on the claim form.
Charges on Claim:
- M79: The charge is missing, incomplete, or invalid.
Solution: Ensure a charge is entered for each service listed on the claim form.
Date Range Not Valid with Units Submitted:
- M52: The “from” service date(s) is missing, incomplete, or invalid.
- N345: The date range is not valid based on the units submitted.
Solution: Ensure that the date(s) of service corresponds to the number of units billed. If multiple units are billed on a single day, consider itemizing the services or providing additional line items.
Facility ZIP Code:
- N104: The claim service is not payable under the claims jurisdiction area.
Solution: Enter the service facility’s correct state and ZIP codes on the claim form.
Facility/Laboratory Name and Address:
- N294: The service facility’s primary address is missing, incomplete, or invalid.
- MA114: Information about where the services were furnished is missing or incomplete.
Solution: Provide the complete service location name, address, city, state, and ZIP code on the claim form. If required, enter the service facility’s NPI.
Purchased Service/Primary Provider Identifier:
- N270: The other provider’s primary identifier is missing, incomplete, or invalid.
- N283: The purchased service provider identifier is missing, incomplete, or invalid.
Solution: Enter the valid performing physician/supplier NPI and their information on the claim form.
ICD Diagnosis Codes:
- M76: The diagnosis or condition is missing, incomplete, or invalid.
- M81: Ensure coding to the highest level of specificity.
Solution: Enter up to 12 diagnosis codes in priority order, using the highest level of specificity.
Incorrect Claim Form/Format:
- N34: The claim form or format is incorrect for this service.
Solution: Ensure the correct claim form and format are used, and maintain consistency with the date format throughout the claim.
It is important to review any remark codes provided to understand the specific information required for each denial. Contacting the payer for clarification and following their instructions for resubmission is crucial to resolve CO 16 denials effectively.
Ordering or referring physician name, qualifier, and NPI:
- N264: The ordering provider’s name is missing, incomplete, or invalid.
- N265: The ordering provider’s primary identifier is missing, incomplete, or invalid.
- N276: The other payer referring provider identifier is missing, incomplete, or invalid.
- N285: The referring provider’s name is missing, incomplete, or invalid.
- N286: The referring provider’s primary identifier is missing, incomplete, or invalid.
Solution: Refer to Items 17 and 17b on the claim form. Please enter the name of the referring, ordering, or supervising physician in Item 17 using their individual provider’s name, not the group name.
Physician/Supplier Signature:
- MA81: The provider/supplier signature is missing, incomplete, or invalid.
Solution: Refer to Item 31 on the claim form. The physician/non-physician practitioner’s signature is required. Acceptable formats include an actual signature, a “Signature on file” notation (if applicable), or a computer-generated signature.
Primary or Secondary Payer Information:
- MA83: It was not indicated whether we are the primary or secondary payer.
Solution: Refer to Item 11 on the claim form. This is a required field. By completing this item, the physician/supplier acknowledges that they made a good faith effort to determine whether Medicare is the primary or secondary payer. If Medicare is the primary insurance payer, enter “NONE.” If Medicare is the secondary insurance payer, enter the insured’s policy or group number, and continue to Items 11a-11c.
Procedure Codes:
- M51: The procedure code(s) are missing, incomplete, or invalid.
Solution: Refer to Item 24D on the HCFA claim form. Select a valid procedure code using the most current year’s Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) code(s) based on the date(s) of service on the claim.
Rendering Physician NPI:
- N290: The rendering provider’s primary identifier is missing, incomplete, or invalid.
MA112: Group practice information is missing, incomplete, or invalid.
Solution: Refer to Items 24J and 33 on the claim form. For services rendered by a provider in a group, enter the individual provider NPI in Item 24J in the unshaded portion of the field. Do not enter anything in the upper shaded portion. Do not enter the group NPI in this field (Billing group NPI goes in Item 33a). The rendering provider must be associated with the group indicated in Item 33.
For services rendered by a non-physician practitioner (e.g., laboratory technician, ultrasound technician, radiology technician), enter the supervising physician’s NPI. Enter the billing group’s name, address, ZIP code, and telephone number in Item 33.
In conclusion, when receiving a CO 16 denial code from a commercial payer, it is important to first check for any remark codes provided on the ERA, paper EOB, or the payer’s website. Contacting the payer for clarification and following their instructions for resubmission is crucial to resolve CO 16 denials effectively.