Denials

Expenses incurred after coverage terminated. Description This denial occur when the date of service lies after the coverage terminated date. 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 most important step is […]

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,

Missing/incomplete/invalid CLIA certification number. Description This denial occurs when CLIA certification number is required but missing in the claim. It may also occur when we use an outdated or wrong CLIA certification number. Actions First, we need to verify the status of the claim. This can be done by checking the claim status through 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 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

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

Missing/incomplete/invalid/deactivated/withdrawn National drug code (NDC). Description NDC is required for drug procedure codes that start with alphabets, such as J7649. This denial occurs when NDC is required but missing in the claim. It may also occur when we use an outdated or wrong NDC. Actions First, we need to verify the status of the claim.

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

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

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