The Top 10 Reasons Claims Get Denied

Understanding the reasons why medical claims get denied by insurers can help limit the number of denials your medical office receives. The only way to prevent them is to be aware of what they are.


Incorrect Patient Identifier Information

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It is important to file a medical claim with accurate patient identifier information. Without this pertinent information, the health insurance plan cannot identify the patient to make payment or apply the claim information is applied to the appropriate patient health insurance account.

Some of the most common mistakes that can cause a claim to deny due to incorrect patient identifier information are:

  • The subscriber or patient's name is spelled incorrectly.
  • The subscriber or patient's date of birth on the claim doesn't match the date of birth in the health insurance plan's system.
  • The subscriber number is missing from the claim or invalid.
  • The subscriber group number is missing or invalid.

Coverage Terminated

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Verifying insurance benefits prior to services being rendered can alert the medical office if the patient's insurance coverage is active or has terminated. This will allow you to get more up-to-date insurance information or identify the patient as a self-pay.


Requires Prior Authorization or Precertification

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Many services considered as non-emergency-related may require prior authorization. It is customary for most insurance payers to require prior authorization for expensive radiology services such as ultrasound, CT, and MRI. Certain surgical procedures and inpatient admissions may also require prior authorization.

Services that are provided to a patient that require prior authorization will likely be denied by the insurance payer. Services will not be denied if the services rendered are considered as a medical emergency. The provider may attempt to get a retro-authorization within 24 to 72 hours after the services are received depending on the insurance payers guidelines.


Services Excluded or Non-covered

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Exclusions or non-covered services refer to certain medical office services that are excluded from the patient's health insurance coverage. Patients will have to pay 100% for these services.

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.


Request for Medical Records

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Some health insurance plans may request medical records when the claim requires further documentation in order to adjudicate the claim. The medical record includes but not limited to the following:

  • Patient medical history
  • Patient physical reports
  • Physician consultation reports
  • Patient discharge summaries
  • Radiology reports
  • Operative reports

Coordination of Benefits

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Coordination of benefit denials could include:

  • Other insurance is primary
  • Missing EOB (estimate of benefits)
  • Member has not updated insurer with other insurance information

Coordination of benefits is a term used when a patient has two or more health insurance plans. Certain rules apply to determine which health insurance plan pays primary, secondary or tertiary. There are several guidelines to determine in what order the medical office must bill each health insurance plan.


Bill Liability Carrier

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

For accident-related services, the following third party liability insurance should always be filed as primary:

  1. Motor Vehicle or Auto Insurance including no fault, policy or Med Pay
  2. Worker's Compensation Insurance
  3. Home Owner's Insurance
  4. Malpractice Insurance
  5. Business Liability Insurance

Missing or Invalid CPT or HCPCS Codes

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In order for medical claims to process correctly, there are standard codes used to identify services and procedures. This system of coding is called the Healthcare Common Procedure Coding System (HCPCS and pronounced "hicks picks").

Make sure your medical coders stay up-to-date on HCPCS codes. Changes to HCPCS codes are updated periodically due to new codes being developed for new procedures and current codes being revised or discarded.


Timely Filing

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Be aware of timely filing deadlines for each insurance carrier. Some examples of timely filing deadlines include:

  • United Health Care: Timely filing limits are specified in the provider agreement
  • Cigna: Unless state law or other exception applies -
    • Participating health care providers have three (3) months (90 days) after the date of service.
    • Out-of-network providers have 6 months (180 days) after the date of service.
  • Aetna: Unless state law or other exception applies -
    • Physicians have 90 days from the date of service to submit a claim for payment.
    • Hospitals have one year from the date of service to submit a claim for payment.
  • TRICARE: Claims should be submitted within one year after the date of service.

No Referral on File

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

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