Healthcare Claims: Validation, Authorization, and Hold Codes

Posted on Mar 8, 2025 in Graphic Arts

This document outlines the validation and authorization processes for healthcare claims, including exceptions and hold code applications.

Validation

  • Member validation: ME1014 – member ID & member date of birth.
  • Provider validation: PR1011 – tax ID.
  • Claim validation: CL1032/CL1033 – DOS, POS, modifiers, service codes, charge amount, DX codes.
  • Plan: CL10323/CL1033 – (SHP – CC – QHP – NSD & MSO)

Authorization

Validate & search valid authorization in (CCMS/CL1011/Evicore(radiology)/Trucare 4 exchange plan)

Validation:

Authorization Tab

  • Event status: approval/pending/denial.
  • Bubble comments (negotiated rate).
  • Closed reason (if it is “void,” don’t consider auth).
  • Decision date.
  • Start date & end dates.
  • Provider details (provider tax ID, name, network status (in or out-of-network)).

Line Item Tab

  • Service codes.
  • Bubble comments.
  • Units – CL1011

Authorization Not Required (Exceptions)

  • Anesthesia providers (except: exchange plan).
  • Dialysis codes 90935, 90937, 90999.
  • Behavioral mental health: POS 23, in-network.
  • Emergency room & urgent care, POS 20 & POS 23 (both in/out-of-network)
  • COB claims.
  • DME – hearing exams & hearing aids, in-network.
  • Transitional care codes (hold code TD, TR, !1 or !2)

Hold Code 42

  • No fee schedule.
  • Charges $0.00 or $0.01 V & E.
  • Check CCMS for a negotiated rate; apply negotiated rate.
  • Use toolkit; choose the hold code 42 button; enter DOS year, POS & charge amount. Toolkit will generate allowed amount; use toolkit amount in allowed amount field.
  • Service codes 99201-99205; 99211-99215; T1013; 90863 don’t apply hold code TZ.
  • For all other service codes, apply hold code TZ.
  • Update notes in CL1083 screen.
  • Revenue codes 022, 023 & 024 for all POS. Apply hold code A9.
  • Only rev code no CPT. Apply hold code A9.
  • 1 service line R billed only rev code – apply hold code B4.

Exceptions: Do Not Apply Hold Code 42 Rules

  • APC priced (hold code PK, 2G, 5F)
  • APG priced (hold code PJ, &/ QM)
  • Ambulatory surgery (POS 24) hold code TL.
  • Inpatient claims (POS 21)
  • SNF claims (rev codes 191-194 or 100, 101, 120 etc.)
  • Dialysis claims POS 65
  • Negotiated rate is listed in CCMS.
  • In or XN C-codes – apply hold code BT.

COB – Review

  • EDI claims: other insurance information or other amounts populated.
  • Professional claims: hold code QY, 10, 22, 16.
  • Paper claims: claim image include an EOB.
  • Hold code QY & D1 – verify & adjudicate the claim.

PCP

  • Review priority code – ME1013.

Priority code = 1 other insurance is primary (EOB required)

Priority code = 2 Health First is primary.

  • Hold code QY – VL – bubble stating Medicare is primary – deny hold code HZ.
  • Apply provider paid amount in COB field.
  • Apply hold code DF (primary carrier was equal to the HF allowed amount) & hold code 16.
  • Behavioral health, non-emergent codes (A0428, A0425..) apply 100% of co-pay or co-insurance.
  • SNF claims – 100% of co-pay or co-insurance. Hold code 16 on all lines.

COB – Exceptions

  • Authorization not required.
  • Different modifier – image between EOB – apply hold code HZ.
  • Hold code QY & D1 – verify & adjudicate the claim.

SNF-Service Codes

100 – 101 – 190 – 120 – 123 – 124- 160 – 169 – 183- 185 – 199 – 191 – 192 – 193 – 194.

  • 022 – apply hold code DB.
  • Other charges 250, 350, 450 etc. apply hold code AA.
  • No fee schedule.
    • Review CCMS bubble comment. If negotiated rate listed, pay negotiated rate.
    • If there is no negotiated rate, use benchmark rate sheet; apply allowed amount.