Denials

Procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to national correct coding initiative or worker compensation state regulations or fee schedule requirements. Description For the use of modifiers, we must keep in mind their proper combination with the CPT code. If a modifier is […]

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

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

Non covered services because this is not deemed as medical necessity by the payer. Description This denial occurs when the insurance does not consider the services provided to be medically necessary based on the patient’s health condition. Sometimes, an incorrect diagnosis code is appended, which can also lead to this denial. Actions First, we need

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

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

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

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

Expenses incurred prior to the coverage start. Description This denial occur when the date of service lies before the coverage start date of insurance. 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

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