15 Common Reasons for Claim Denial
1. A duplicate claim was submitted when a practice hasn’t received reimbursement.
2. The patient isn’t eligible for services because his or her health plan coverage ended, and the patient hasn’t shown proof of new insurance.
3. A patient hasn’t met the deductible for the calendar year.
4. Some services are bundled. For example, laboratory profiles with multiple test don’t qualify for separate reimbursements, or an all-encompassing rate covers the minor procedure and the pre- and post-procedure visits. The provider receives one combined payment.
5. The benefit has been exceeded, such as the maximum allowed number of physical therapy visits covered by the health plan within a calendar year.
6. The claim form is missing a modifier or modifiers, or the modifier(s) are invalid for the procedure code (as in the case of bilateral codes billed on both sides).
7. An inconsistent place of service is marked on the claim form, such as an inpatient procedure billed in an outpatient setting.
8. A particular service isn’t covered under the plan’s benefits, or there appears to be a lack of medical necessity. In another example, there could a mismatch between the actual diagnosis and the service performed.
9. The claim is deficient in certain information. It may be missing prior authorization or the effective period of time within which the pre-approved service must be provided for reimbursement to occur.
10. When the physician isn’t an in-network provider, the insurer may pay a lesser amount if the patient has out-of-network benefits.
11. There is a coding or data error with mismatched totals or mutually exclusive codes.
12. It may be necessary to coordinate benefits when dual coverage issues arise, such as with secondary insurance of worker’s compensation.
13. The filing deadline has passed. If a claim isn’t submitted to the insurer within the permitted time frame, it is likely to be rejected. The limit to file cab be as short as 90 days from the date of service.
14. Errors or typos were made while collecting pertinent information from the patient or during the data entry process for a claim.
15. The claim includes outdated current procedural terminology (CPT) codes, or it lists deleted or truncated diagnosis codes.
UBM Medica, LLC, a UBM company.
Posted: May 8, 2014
Posted by: Kimberly Dues CPC, CRC, ICD-10 CM
Mass Medical Billing Services