arbababbasi525@gmail.com

This claim/service not covered by this payer/contractor. You must send the claim/service to correct payer/contractor. Description This denial mostly occurs when we mistakenly bill claim to the wrong payer/ insurance but the primary insurance is another one. Actions First, we need to verify the status of the claim. This can be done by checking the […]

Charges exceed the fee schedule/ maximum allowable or contracted fee agreement. Description This is basically an adjustment and occurs when the charge amount exceeds the maximum allowable limit or the contracted fee schedule. A fee schedule refers to the predetermined list that defines how much a procedure should be allowed or reimbursed by the insurance.

Precertification/authorization/pre-treatment/notification absent. Description For certain medical treatments, the provider needs to obtain approval from the insurance company, which is referred as authorization, notification, pre-treatment, or precertification. This denial may occur if the services provided require authorization but were not obtained from the insurance. It may also occur if the auth# entered on the claim is

Benefits for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Description This denial occur when insurance considered a service as a part of other service so denied as benefit for this service has already been adjudicated with another service. Actions First, we need to verify the status of

Expenses incurred prior to the coverage start. Description This denial occur when the date of service lies before the coverage start date of insurance. Actions First, we need to verify the status of the claim. This can be done by checking the claim status through the insurance web portal or by calling the payer. The

Rendering provider is not eligible to perform for the service billed. Description This type of denial most often occurs when the rendering provider’s specialty is different. It also may occur when the rendering provider is not enrolled with the insurance or group. Sometimes it also may occur when the rendering provider information is missing in

Procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to national correct coding initiative or worker compensation state regulations or fee schedule requirements. Description For the use of modifiers, we must keep in mind their proper combination with the CPT code. If a modifier is

Missing/incomplete/invalid/deactivated/withdrawn National drug code (NDC). Description NDC is required for drug procedure codes that start with alphabets, such as J7649. This denial occurs when NDC is required but missing in the claim. It may also occur when we use an outdated or wrong NDC. Actions First, we need to verify the status of the claim.

Missing/incomplete/invalid CLIA certification number. Description This denial occurs when CLIA certification number is required but missing in the claim. It may also occur when we use an outdated or wrong CLIA certification number. Actions First, we need to verify the status of the claim. This can be done by checking the claim status through the

Patient/insured health identification number (member ID) or name mismatch. Description This denial occurs mostly when we billed claim with incorrect patient/insured name, or member ID. Actions The most important step is to determine whether the claim denial is valid or if the insurance has denied the claim by mistake. Call the insurance company and ask