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Denials

Common denials on medical billing

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haya Arman
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104 views2 pages

Denials

Common denials on medical billing

Uploaded by

haya Arman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Eligibility and Coverage Denials

• Example: The patient is not eligible for coverage on the date of service.

• Cause: Verification of coverage wasn't done, or insurance information is outdated.

• Resolution: Confirm eligibility with the insurer before submitting claims, and update patient
records regularly.

Authorization or Pre-Certification Denials

• Example: Services provided require prior authorization, but authorization was not obtained.

• Cause: The provider did not get the necessary pre-approval for a procedure or service.

• Resolution: Ensure that authorization requirements are reviewed, and approvals are obtained
before treatment.

Medical Necessity Denials

• Example: The service is deemed not medically necessary based on insurance guidelines.

• Cause: The diagnosis or procedure code submitted doesn’t justify the necessity for treatment.

• Resolution: Review and understand payer-specific medical necessity guidelines, and adjust
documentation to support claims.

Duplicate Claim Denials

• Example: Submitting the same claim multiple times.

• Cause: Claims are resubmitted without any change in response to a pending or denied status.

• Resolution: Track claims carefully, and resubmit only if necessary with adjustments or
clarifications.

Coding Errors (Incorrect or Incomplete Codes)

• Example: Errors in procedure or diagnosis codes (e.g., incorrect CPT or ICD-10 codes).

• Cause: Coding errors or omissions in the claim.

• Resolution: Verify codes with the medical coding team, and use automated tools or software to
minimize errors.

Coordination of Benefits (COB) Issues

• Example: Insurance has not determined the correct primary payer.

• Cause: Multiple insurers are involved, and COB isn’t properly coordinated.

• Resolution: Confirm which insurer is primary, secondary, etc., and communicate this clearly on
claims.

Claim Timeliness (Late Filing)


• Example: The claim was submitted after the insurer’s deadline.

• Cause: Delays in submission, often due to lack of proper follow-up.

• Resolution: Familiarize with payer deadlines and set up reminders for timely submissions.

Invalid or Missing Information

• Example: Missing patient details, provider NPI, or insurance ID number.

• Cause: Claims submitted with incomplete information.

• Resolution: Double-check all required fields on the claim form, and use automated claim checks
if available.

Bundling and Unbundling Issues

• Example: Services are bundled by the insurer but submitted separately.

• Cause: Unbundling procedures or failing to recognize bundled service rules.

• Resolution: Understand bundling policies for each insurer to properly code bundled services.

Place of Service Mismatch

• Example: The place of service code does not match the service provided.

• Cause: Incorrect place of service code submitted with the claim.

• Resolution: Verify that place of service codes align with the type and location of service
provided.

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