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Non covered charges. Description This denial falls into two categories. Non-covered charges as per the patient’s plan. This occurs when either the provider is out-of-network (OON) or the diagnosis (DX) or procedure code (CPT) is not covered under the member’s plan. Non-covered charges as per the provider contract. This occurs when the procedure is not […]

Procedure code is inconsistent with Patient’s age. Description This denial occurs when the procedure code billed is not compatible with age of the patient. There are certain procedure codes that are age-specific, and if we bill one of these codes for a patient whose age does not match the requirements of the code, the claim

New patient criteria not met. Description If a patient visited the doctor within the last 3 years, then they would be considered an established patient. If more than 3 years have passed since the last visit, then they would be considered a new patient. There are procedure codes that specifically differ based on whether the

Missing document. An attachment is needed to process the claim. Description This denial occurs when the insurance requires documentation to process the claim. This denial mostly occurs when the insurance requires medical records to validate the services. Actions First, we need to verify the status of the claim. This can be done by checking the

Procedure code is inconsistent with Provider’s type/specialty/taxonomy. Description This denial occurs when the procedure code billed 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 procedure code is billed that does not fall within the

This injury/illness is liability of no-fault carrier. Description This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to np-fault carrier. Sometimes, even if the illness is not related to no-fault carrier, using an incorrect diagnosis that indicates a no-fault carrier related injury and

This injury/illness is covered by the liability carrier. Description This denial mostly occurs when a claim is billed to a commercial payer, but the injury or illness is actually related to liability carrier. Sometimes, even if the illness is not related to liability carrier, using an incorrect diagnosis that indicates a liability carrier related injury

Patient cannot be identified as our insured. Description This denial occurs mostly when we billed claim with incorrect patient name, gender or DOB. 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 the representative

Attachment or other document referenced on the claim was not received. Description This denial occurs when the documents referenced on the claim have not been received by the payer. In most cases, a remark code will be provided that clearly specifies which document is required but has not yet been received. For example, if the

Non covered services as it is a routine/ preventive exam or a diagnostic/ screening procedure done in conjunction with a routine/ preventive exam. Description This denial occurs when a claim is billed with routine diagnosis codes (diagnosis code start with Z). It can be resolved by changing routine diagnosis with another proper diagnosis code. Actions