Claim denied by insurance - Denial reason and follow up answer

Claim denial types
There is no particular type in denial however below are the common reason
Claim might be denied for incorrect coding information.
Claim might be denied for incorrect provider information.
Claim might be denied for incorrect coverage information
Claim might be denied for lack of information

 Claim denials by managed care organization plague long-term care providers
Should be file the claim to patient HMO plan


Claim denials for maximum unites per visit
Check your units of the CPT

Claim denied as inclusive with the primary procedure
Some service covered with primary procedure, Hence we needs to taken write off the claim balance after primary CPT paid. However there is chance with resubmit the inclusive procedure with modifier.


Claim denied as services not provided or authorized by designated
File the claim along with appropriate authorization#. If we don’t have authorization# sometimes we can appeal the claim along with necessary medical document.

Claim denied because of incorrect medical coding
Should be file the claim with correct diagnosis (Dx) and CPT

Claim denied because this injury is the liability of the no-fault carrier.
Should be file the claim to patient auto-insurance.

Claim denied by medicaid because primary insurance changed
File the claim to patient primary insurance. If we don’t have patient primary insurance details needs to call the patient and get the insurance information.

Claim denied by medicare for code co-16 what do i do to get this paid?
      We will receive this denial if we have filed the claim with insufficient information. This code co-16 must have additional denials information that informs us what kind of information is missing with claim.


Claim denied due to pre-existing condition
Patient needs to update the medical (medical history) document to insurance and provider also update the medical document to insurance.

Claim denied for CLIA certification#
Should be file the claim with clia certification number. We must file the lab code with clia number.

Claim denied for coordination of benefits
Patient needs to update the COB information to insurance. If patient has more than one insurance, patient need to call the insurance and inform that which insurance is primary and secondary for patient. Patient only can update the COB information to insurance.

Claim denied for maximum benefits reached

File the claim to secondary along with denied EOB. If patient do not have another insurance we can bill the patient.


Claim denied for valid referral

Should be file the claim with valid referral. If we do not have valid referral number, we can request the same from referring doctor and refile the claim with valid referral.


Claim denied no billing code.
Kindly call the insurance and get the reason behind the denials and get the correct CPT

Denied benefits is not covered by the patient's plan.

 We can bill the patient.

Denied insurance claims due to invalid CPT code
     Should be file the claim with valid CPT. For example medicare and HMO plans (Humana, freedom health, AVMED, universal, wellcare, Polk county, PUP,) does not cover the consultation code (99241 to 99245 and 99251 to 99255).

Claim denied reason dates of service over one year from process date are not payable.
    Should be file the claim with in timely filing limit. If you received the denial even filed the claim with in TFL we can appeal the claim with TFL proof. All insurances has separate filing limit.


Claim denial codes and what action needs to be taken
Each denied claim should have valid reason behind the claim denial and needs to take appropriate action from the denials


Claim denial vs claim rejection
Claim denied by insurance and claim rejected by clearing house OR EDI department

Claim denials bundling inclusive
Needs to differentiate the service by using appropriate modifier and Dx else taken write-off the claim balance

 Claim denied primary paid in full
Need to write-off the claim balance.

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