Quick Explanation
Denial code 23 indicates that a secondary or tertiary payer has adjusted or denied payment based on the adjudication, payments, or contractual write-offs of the primary insurer. It signifies that the primary payer's payment met or exceeded the secondary payer's allowed amount, resulting in no additional reimbursement. This code is commonly used during coordination of benefits (COB) processing to communicate how the primary payer's payment impacted the remaining liability.
Common Causes for 23
Denials with code 23 typically happen for the following specific reasons:
- The primary payer's payment met or exceeded the secondary payer's allowed fee schedule rate, resulting in a zero-dollar secondary payment.
- Missing or incomplete coordination of benefits (COB) data, such as failing to transmit the primary payer's Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) details.
- Mismatched claim information, such as differing CPT codes, modifiers, or billed charges, between the primary claim submission and the secondary claim.
- Incorrect mapping of primary payer adjustment group codes and reason codes (CARCs/RARCs) on the secondary electronic claim transaction (837).
How to Prevent 23 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Ensure all coordination of benefits (COB) data, including the primary payer's paid, allowed, and patient responsibility amounts, is fully and accurately populated on secondary claims.
- Perform rigorous eligibility and insurance hierarchy verification at the time of service to confirm correct primary and secondary payer sequencing.
- Cross-reference secondary claims against the primary EOB to verify that CPT codes, modifiers, and billed charges match exactly prior to submission.
- Utilize automated billing software scrubbers to validate that primary adjudication details are completely mapped to the secondary claim's Loop 2430 (SVD segment).
Appeal Letter Template for 23
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 23 - The impact of prior payer(s) adjudication including payments and/or adjustments
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 23: "The impact of prior payer(s) adjudication including payments and/or adjustments".
We are writing to appeal the adjudication of this claim under Denial Code 23 regarding coordination of benefits. According to the CMS Medicare Secondary Payer (MSP) manual and industry-standard COB guidelines, secondary payers must evaluate the primary payer's adjudication—including deductibles, copayments, and co-insurance—to determine the correct secondary liability. The enclosed primary Explanation of Benefits (EOB) clearly details the primary payer's allowed amount, paid amount, and the remaining patient responsibility. As the service was medically necessary and billed in accordance with AMA CPT guidelines, we request that you review the attached primary payment details and adjust your payment to cover the remaining balance up to your contracted allowable rate.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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