Providing free resources and useful informations for Physicians,
Office Managers, Medical Billers and Medical Coders
10 Common Reasons Claims
Gets Denied
(1) Incorrect patient’s information (insurance ID# , date of birth):

numbers because these characters can be recognize by electronic as unrecognizable.

Always make a copy of your patient's primary & secondary insurance card on file (copy
front and back!). Make sure to get a copy of their new card (if there is a change).

(2) Patient’s non-coverage or terminated coverage at the time of service may
also be the reason of denial:

That is why, it is very important that you check on your patient’s benefits and eligibility
before see the patient (unfortunately, I have seen practices who does not check on
benefits and eligibility on their patients so they end being not paid for the service they
rendered for the patient)

(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful also
with your secondary code! Claims may be denied even if the problem was just because of
the secondary CPT/ICD9 code!

Again as I previously pointed out with my other articles on tracking your claims, with this
problem, discuss solving the coding error rather than how much you want to get
reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and
they also inform you on outdated codes, or codes that requires a 5th digit.

(4) Incorrect use of modifiers! (be careful with bilateral procedures!, modifiers for
professional and technical component, modifiers for multiple procedures, postoperative
period, etc.)

(5) No precertification or preauthorization obtained (if required): It is so hard to file
an appeal when the claim or service was non-precertified. Avoid it from happening!

(6) No referral on file (if required) Note: HMOs normally requires a referral!
(remember that!)

(7) The patient has other primary insurance or the patient’s claim is for workman’
s comp or auto accident claim!

It is the responsibility of your front desk staff to get all the necessary information before
the patient can be seen. Remember that if this is a workman’s comp or an auto accident
claim, you need a claim number and the adjustor’s name. Services are normally always
preauthorized and requires prior authorization!

(8) Claim requires documentation & notes to support medical necessity. A well
documented medical records is a good practice!

(9) Claim requires referring physician’s information

(10) Untimely filing
- Unfortunately most of the insurances does not accept your billing
records on your office computer that shows that date(s) you billed the insurance! They
want a receipt from your electronic receipt or for postal mail, obviously they want a receipt
too! a tracking number maybe? certified letter receipt?

If you are submitting claims by electronic, make sure you generate transmission
reports/receipts. Your reports must read "accepted" and not "rejected". File all these
transmittalreports/ and
receipts and a very safe place!

If you are sending claims by paper or postal mail, it is a good idea to send your claims as
certified mail with tracking number, keep your transmission receipts!!

CPT codes and its descriptions are copyrights, owned, maintained and is a trademark of the AMA
(American Medical Association).
*** Always consult your CPT Code Book! and the NCCI Edits
*** Get more information on clinical guidelines and policies from your local CMS carriers and from your
third party payors
*** You can purchase CPT Code books and CPT Assistants issues from the
AMA's Bookstore!
Read What's NEW  
Related Topics That You Want to Read