AI Assistant
MASE Intelligence · Claim analysis, denial prevention, and coding guidance
Why was CLM-2025-001848 rejected by Aetna?
Claim CLM-2025-001848 (Dr. Sandra Okafor · $1,240.00 · Aetna) was rejected with denial code CO-4: Service/Procedure not covered by this payer.
Root Cause: CPT codes 90837 and 90791 were submitted without a pre-authorization reference number in segment 2300.REF. Aetna requires pre-auth for 90837 when more than 8 sessions have been provided.
AI Recommendation: 1. Verify whether a pre-authorization exists on file for patient PT-29034 2. If authorization exists, add the auth number to field 2300.REF*G1 and resubmit 3. If no auth exists, submit a retroactive authorization request to Aetna — success rate for retro-auth on behavioral health is ~42% per your org's historical data
Revenue at risk: $1,240.00 · Priority: High
What modifier should I add to CPT 93306 with 93458 for UHC?
When billing CPT 93306 (Echocardiography) alongside 93458 (Cardiac catheterization) to UnitedHealthcare, you must apply a component billing modifier split:
- Add Modifier -26 (Professional Component) to 93306 if billing for interpretation only - Add Modifier -TC (Technical Component) if billing for the equipment/facility portion separately
Per UHC Companion Guide v4.7: These procedures are designated "mutually exclusive" when billed together on the same date of service.
This matches CLM-2025-001850 — I've flagged this claim and held it for your review before routing to UHC. Would you like me to apply Modifier -26 and release the claim?