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Payer deems the submitted information does not support this level of service. Description This denial mostly occurs due to coding issues (medical necessity). Sometimes, reaching the maximum benefits for a service may also cause this denial. Sometimes, this denial may also occur if the insurance requires medical records to support the service. Actions First, we […]

This procedure is not paid separately. Description There are certain procedures that cannot be billed alone and require a primary procedure code for reimbursement. If the procedure is billed without the primary procedure, or if the wrong primary procedure is used, this denial is received. Actions First, we need to verify the status of the

Procedure code is inconsistent with Place of service. Description This denial occurs when the procedure code billed is not compatible with the place of service reported on the claim. For example, if we bill a procedure code that is meant only for outpatient services, such as 99213, but use POS 21 (which is specifically for

Provider was not eligible/certified to be paid for this procedure/service on this DOS. Description This denial mostly occurs when the provider is not eligible to perform the billed services on the mentioned DOS. Actions First, we need to verify the status of the claim. This can be done by checking the claim status through the

Benefit maximum for this period or occurrence has been reached. Description Sometimes, a policy places limits on certain services or procedures, allowing payment only up to a specified dollar amount or number of visits per year or lifetime maximum. Once the service reaches that limit, the insurance denies the claim. For example, if a service

Patient enrolled in a hospice. Description When a patient is diagnosed with a disease that cannot be treated, or with a disease that could be treated but the patient refuses treatment due to its life-threatening nature, and the patient has a life expectancy of less than six months, then the patient becomes eligible for hospice.

Information requested from patient/insured/responsible party was not provided or was insufficient/incomplete. Description This denial is related to information requested from the patient, such as Coordination of Benefits (COB) or other required details. It mostly occurs when the requested information is not provided. When the insurance requests information from the patient, they send a letter to

Modifier was invalid on the date of service. Description This denial occurs when the insurance considers the modifier used was invalid for date of service (DOS) reported. 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

Procedure code is inconsistent with Patient’s gender. Description This denial occurs when the procedure code billed is not compatible with patient’s gender. There are certain procedure 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

This is a work related injury/illness, so liability of worker compensation. Description This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to worker’s compensation. Sometimes, even if the illness is not work-related, using an incorrect diagnosis that indicates a work-related injury can also