Denial Reason in Medical Billing - Patient Not Found in System

Member not in the system


“Patient Not Found or Patient Not in System” is one of the common denials found in Medical Billing. It may be due to some incomplete information in the claim form or due to some errors. In Medical Billing errors are inevitable. They are a fact of medical billing, even with the advent of electronic medical records (EMRs). Usually Medical Billing companies deal with a lot of Medical Practices, Hospitals, Doctors etc, and it should comply with each one of their process of filing claims. This is one of the key reasons for errors occurring in Medical Billing.

“Patient Not found” denial occurs due to one of the following reasons:

1) Incorrect insurance information furnished by the patient in the Doctor’s office.

2) Incomplete information given in the claim form by the Medical Biller, like

incomplete ID #, incorrect patient name etc.,

3) Insurance policy of the patient would have been terminated long before, and the insurance company would have lost track on the patient’s information.


4) Patient would have been not included in the policy as a member (this occurs incase of dependent members).

5) The Medical Billing Company files the claim with a wrong insurance company.

Once this denial has occurred, it could be overcome by calling the Patient and checking the appropriateness of his/her insurance policy, and re-filing a new claim with the correct information. Else if the patient does not have a valid insurance coverage at the time of the treatment, the entire bill should be directed to the patient.

This denial could be avoided by getting the accurate insurance information from the patient at the first visit itself, and then checking the eligibility and benefits verification of the patient’s policy by calling the insurance company, and also by concentrating more on minimizing the errors, and filing a clean claim with the insurance company.



Medicare denial A1 B1 B4 AND B6

Pre-existing condition denial

Benefit exhausted denial and action

Insurance claim denied

Denial claim

Medicare denial reason codes

Medicare EOB reason codes

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