Denials

Procedure/service was partially or fully furnished by another provider. Description This denial occurs when multiple providers billed the same service on the same DOS. 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 […]

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

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

Diagnosis code is invalid for the DOS reported. Description This denial occurs when the insurance considers the diagnosis code billed 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

Impact of prior payer including payments and adjustments. Description This denial mostly comes from the secondary insurance. This denial occurs when the primary insurance payment is equal to or greater than the secondary insurance’s allowed amount. Let’s understand this with example. Let us consider an example where the primary insurance allows $50, pays $40, and

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

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

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

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

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