Denials

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 […]

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

Deductible is contracted (between member and insurance) $ amount member have to pay before insurance start to pay. It always come with PR category. Example A patient has a contracted deductible of $1,000. When the patient visits the doctor, the insurance company reviews the claim and allows $800 for the services performed. Since the deductible

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

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

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

The time limit for filing has expired. Description This denial occurs when a claim or appeal is submitted to the insurance company after the timely filing limit has expired. 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

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

Patient/insured health identification number (member ID) or name mismatch. Description This denial occurs mostly when we billed claim with incorrect patient/insured name, or member ID. 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

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