OK to deny claims if no Certificate of Creditable Coverage is provided

[Guest LTP]

I'm in need of some information cencerning Certificates of Creditable Coverage and claims administration. We are a TPA and when we enroll a new employee we request a copy of his COCC. If it is not received in 30 days, we send a second letter. If that second letter is not recieved in 30 days, all claims we have pending are denied with the reason "Certificate of Creditable Coverage not recieved."

My feeling is that we should not be denying these claims for a lack of a COCC, but rather, at that point, persue preexisting infomation, thereby treating the individual as someone who does not have any creditable coverage. And if the employee sends the COCC later, reprocess any necessary claims.

I would appreciate anyone's opinion on this. I'm uncomfortable in denying claims based on information that is only necessary for the possibility of a preexisting condition.

Thanks for any help!

[Guest Damien]

When you say "all claims we have pending are denied" are these the claims pended because you see a possible pre-x condition on those particular claims, or are you pending every claim received on the member? I would hope only the former, as it seems improper to me to pend a claim for a COCC when that claim could not concievably be affected by pre-x one way or the other.

I agree with your idea of treating the individual as someone with no creditable coverage until they produce documentation to the contrary, provided you have made an effort to obtain the certificate from the member. I would personally avoid using a remark code such as the one you described, since the member is not really required to send you what you are asking for. I think you're on safer ground with a remark code identifying claims as excluded under pre-x.

When the member realizes claims are or will be denied under a pre-existing exclusion, you'd be amazed how fast those elusive certificates materialize.

[Kirk Maldonado]

You should read the HIPAA regulations. They provide guidance on how to deal with situations like this.