Denial Codes - Healthcare

CO 15 Denial Code – The authorization number is missing, invalid, or does not apply to the billed services or provider

Channagangaiah

If the services billed require authorization, then insurance will deny the claim with CO 15 denial code – The authorization number is missing, invalid, or does not apply to the billed services or provider, if the claim submitted is invalid or incorrect or with no authorization number.

First let us see the definition of authorization number to understand the denial code CO 15.

What is authorization number?

Authorization number is also called as pre certification number/prior authorization number and should be obtained from insurance company by health care provider. It is a system where certain health care services needs approval from the insurance company, so provider has to obtain approval before the health care provider render those services to patient . By this system it relates not only whether a service of the procedure is covered as per the plan, but also to find out whether it is medically necessary or not. This authorization number will be in the Block number 23 on HCFA 1500.

What are the steps need to be taken, when claim denied with CO 15 denial code – The authorization number is missing, invalid, or does not apply to the billed services or provider?
  • Review previous notes to see if authorization number is available for that particular Date of Service.
  • Review insurance screen in the billing system for valid authorization number.
  • Verify block number 23 on claim form for valid authorization number.
  • Examine any scanned copy of document containing valid authorization number.
  • Review the Place of service is an emergency. If yes, call the insurance company to have the claim reprocessed as emergency service doesn’t require authorization.
  • If the information submitted is already correct, place a call to the insurance claims department and have the claim reprocessed.
  • If the valid authorization # is available, append the claim with correct authorization number and resubmit the claim to insurance company as corrected claim.
  • If there is no information available, place the claims on hold and escalate the claim to client for further action. (Note: If we can get retro authorization from the insurance for the service rendered, then get retro authorization from insurance and resubmit the claim with the obtained retro authorization number)
What are the questions need to ask with rep, when claim denied with CO 15 denial code – The authorization number is missing, invalid, or does not apply to the billed services or provider:
  • Always get the claim received and denied date?
  • First check with rep why authorization number is required for this services and any authorization number on file?
  • If available, check effective and termination date of that authorization and also verify whether this procedure is covered or not? (Also verify the application to see authorization # is available, If available check with rep whether it’s valid or not for the DOS)
  • If yes, reach insurance and direct the claim back for reprocessing.
  • If no, then check whether we can obtain retro authorization for this service (If yes, get the phone number of retro authorization department.).
  • If no retro authorization, get the appeal limit and appeal address or fax# (if necessary appeal the claim along with medical records).
  • Finally obtain claim number and Cal reference number of the denied claim.