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Insurance Verification: Avoiding Denied Claims

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Imagine for a minute that you have received a denial in the mail for an insurance claim and it states that services are not covered or this procedure requires prior authorization. You think for a moment...why didn't someone know about this ahead of time.

Of course, someone would have known if your office had a system in place to make sure that you didn't receive those types of denials. Most insurance denials are due to the lack of verifying insurance benefit information prior to services being provided. The most common denials are:

Requires Prior Authorization

Some medical procedures or services may require the provider to obtain authorization prior to services being performed.

Coverage terminated or member not eligible on this date of service

It is important that providers verify their patient's insurance eligibility each and every time services are provided. Insurance information can change at anytime, even for regular patients.

Services performed are non-covered

Insurance companies and individual policies vary on which medical services they cover. It is great customer service to aware your patient prior to a procedure or service being performed that they may be responsible for it themselves. This way your patient can make that decision ahead of time rather than unknowingly being stuck with a huge bill.

Maximum benefit for this service has been met

This denial is usually reserved for recurring office or hospital visits such a physical therapy, behavioral health services or chiropractic services--just to name a few. Most insurances have a limit to how many visits they allow in a given period.

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