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Referral absent. Description Referral is a recommendation to a patient from Primary Care Physician to receive medical services from another health care provider or medical specialist. In some plans, such as HMOs, a referral from the PCP is necessary to visit a specialist, and if it is not present, the insurance denies the claim with […]

This care may be covered by another payer as per coordination of benefits (COB). Description Coordination of benefits refers to the process used by insurance companies to determine the order (primary, secondary, tertiary) in which multiple insurance plans will pay for a patient’s healthcare services. When a patient is covered under more than one insurance

Non covered services because this is a pre-existing condition. Description If a person wants to purchase a new insurance policy while already suffering from a disease, the insurance may refuse to cover services related to that condition. This existing disease is considered a pre-existing condition. Some plans may provide coverage, but they often come with

Charges are covered under capitation agreement/ managed care plan. Description Capitation is an agreement between a provider and a payer in which the payer pays a fixed amount to the provider per patient for a specific period of time, regardless of the number or cost of services the patient receives. This means a patient may

Date of death precedes the date of service. Description This denial occurs when the date of death (DOD) is earlier than the date of service (DOS). It is not practically possible in real life, and most often this denial occurs due to an error—either in entering the date of service (DOS) during billing or in

Payment made to patient, insured or responsible party. Description This denial mostly occurs when the patient has not signed the Assignment of Benefits (AOB). An Assignment of Benefits (AOB) is an agreement between the member and the insurance company that allows the insurance to pay the provider directly for the patient’s healthcare services. Actions First,

Services not provided by network/ primary care physician. (Services provided by OON provider). Description This denial occurs when the provider is not contracted with the insurance. The basis of this denial is that the provider is out-of-network (OON) while the patient’s plan does not cover OON benefits. Plan types like HMO and EPO do not

Revenue code and procedure code do not match. Description This denial occurs when the procedure code billed is not compatible with the revenue code. 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

Diagnosis code is inconsistent with Provider’s type/specialty/taxonomy. Description This denial occurs when the diagnosis code is not compatible with provider’s specialty, taxonomy.. Each provider has a specialty in a specific field of medicine, such as cardiology, podiatry, physical therapy, or psychology etc. If a diagnosis code used that does not fall within the provider’s specialty,

Procedure code is inconsistent with the modifier used or required modifier is missing. Description A modifier is a two-digit (Numeric or alphanumeric) code added to a CPT or HCPCS procedure code in medical billing. It provides additional information about the service or procedure performed without changing its basic definition. For the use of modifiers, we