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Top 10 Reasons Claims Get Denied

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Hoping to avoid the topic won't make the problem go away. Of course, no one wants to discuss claim denials but the only way to prevent them is to be aware of what they are. Understanding the reasons why medical claims deny can help limit the number of denials your office receives.

1. Incorrect patient identifier information

  • Name spelled incorrectly
  • Date of birth doesn’t match
  • Subscriber number missing or invalid
  • Insured group number missing or invalid

2. Coverage terminated

Verify insurance benefits prior to services being rendered.

3. Requires prior authorization or precertification

You can attempt to file an appeal but most insurance carriers will not reverse their decision.

4. Services non-covered

This is another reason why it is important to contact the patient’s insurance prior to services being rendered. It is poor customer service to bill a patient for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure.

5. Request for Medical Records

6. Coordination of Benefits

  • Other insurance is primary
  • Missing EOB
  • Member has not updated insurer with other insurance information

7. Bill liability carrier

If the claim has been coded as an auto or work-related accident, some carriers will refuse to pay until the auto or worker’s compensation carrier has been billed.

8. Missing or Invalid CPT or HCPCS Codes

9. Timely filing

Be aware of timely filing deadlines for each insurance carrier.

10. No referral on file

Some procedures require that the patient obtain a referral from their family physician prior to services being rendered.

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