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Diagnosis code is inconsistent with Patient’s gender. Description This denial occurs when the diagnosis code billed is not compatible with patient’s gender. There are certain diagnosis codes that are gender-specific, and if we bill one of these codes for a patient whose gender does not match the requirements of the code, the claim will be […]

Non covered services because this is not deemed as medical necessity by the payer. Description This denial occurs when the insurance does not consider the services provided to be medically necessary based on the patient’s health condition. Sometimes, an incorrect diagnosis code is appended, which can also lead to this denial. Actions First, we need

Exact duplicate claim/service. Description This denial mostly occurs when we bill same service/claim of the same date of service more than one time. Sometime we bill the claim twice in error then we receive this denial. In this case the first one processed while the other one denied as duplicate of the first one. Actions

Claim lacks information or has billing/ submission error. Description This denial mostly occurs due to an error in the claim submitted to the insurance or missing some element of claim or because additional information is required by the insurance to process the claim. To identify the exact missing information, we need to review the remark

Diagnosis code is inconsistent with the procedure. Description This denial occurs when the diagnosis code billed is not compatible with the procedure. Diagnosis codes represent the illness or condition, while procedure codes represent the treatment or service provided. If the diagnosis and procedure codes do not align appropriately, the claim will be denied. For example,

Prior processing information appears incorrect. Description This denial is mostly received from secondary or consecutive payers and occurs for two reasons. Primary insurance did not pay the claim. Primary insurance paid the claim, but the payment information submitted on the claim form to the secondary insurance is incorrect. Actions First, we need to verify the

Procedure/ treatment/ drug is deemed as experimental/ investigational by the payer. Description This denial occurs when the insurance considers the services performed to be experimental or investigational. 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

It is a set Price (Portion of bill) patients pays when they visit doctor. This amount is in contract with insurance and depends of the type of plan patient hold. It always come with PR category. Example Let us consider a $30 copayment. This means that the first $30 of every claim allowed amount would

Information requested from the billing/rendering provider was not provided, or not provided timely or was insufficient/incomplete. Description This denial is related to medical records and supporting documentation for the claim. It mostly occurs when the requested medical records are not provided, or they are submitted after the allowed time. Sometimes this denial occurs when medical

Patient’s share of the costs for covered healthcare services, calculated as a percentage of the allowed amount is coinsurance. It always come with PR category. Example Let us consider a 20% coinsurance. This means the insurance company will cover 80% of the allowed amount, while the remaining 20% will be the patient’s responsibility. Imagine a