Denials

Patient enrolled in a hospice. Description When a patient is diagnosed with a disease that cannot be treated, or with a disease that could be treated but the patient refuses treatment due to its life-threatening nature, and the patient has a life expectancy of less than six months, then the patient becomes eligible for hospice. […]

Procedure code is inconsistent with the modifier used or required modifier is missing. Description A modifier is a two-digit (Numeric or alphanumeric) code added to a CPT or HCPCS procedure code in medical billing. It provides additional information about the service or procedure performed without changing its basic definition. For the use of modifiers, we

Benefits for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Description This denial occur when insurance considered a service as a part of other service so denied as benefit for this service has already been adjudicated with another service. Actions First, we need to verify the status of

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

Benefit maximum for this period or occurrence has been reached. Description Sometimes, a policy places limits on certain services or procedures, allowing payment only up to a specified dollar amount or number of visits per year or lifetime maximum. Once the service reaches that limit, the insurance denies the claim. For example, if a service

Diagnosis code is inconsistent with Provider’s type/specialty/taxonomy. Description This denial occurs when the diagnosis code 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 diagnosis code used that does not fall within the provider’s specialty,

Precertification/authorization/pre-treatment/notification absent. Description For certain medical treatments, the provider needs to obtain approval from the insurance company, which is referred as authorization, notification, pre-treatment, or precertification. This denial may occur if the services provided require authorization but were not obtained from the insurance. It may also occur if the auth# entered on the claim is

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

Provider was not eligible/certified to be paid for this procedure/service on this DOS. Description This denial mostly occurs when the provider is not eligible to perform the billed services on the mentioned DOS. Actions First, we need to verify the status of the claim. This can be done by checking the claim status through the

Revenue code and procedure code do not match. Description This denial occurs when the procedure code billed is not compatible with the revenue code. 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