Denials

Charges exceed the fee schedule/ maximum allowable or contracted fee agreement. Description This is basically an adjustment and occurs when the charge amount exceeds the maximum allowable limit or the contracted fee schedule. A fee schedule refers to the predetermined list that defines how much a procedure should be allowed or reimbursed by the insurance.

Payer deems the information submitted does not support this many/frequency of services. Description This denial occurs when a procedure is billed more times than allowed under the reimbursement guidelines. 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

Procedure code is inconsistent with Place of service. Description This denial occurs when the procedure code billed is not compatible with the place of service reported on the claim. For example, if we bill a procedure code that is meant only for outpatient services, such as 99213, but use POS 21 (which is specifically for

Services not provided by network/ primary care physician. (Services provided by OON provider). Description This denial occurs when the provider is not contracted with the insurance. The basis of this denial is that the provider is out-of-network (OON) while the patient’s plan does not cover OON benefits. Plan types like HMO and EPO do not

This claim/service not covered by this payer/contractor. You must send the claim/service to correct payer/contractor. Description This denial mostly occurs when we mistakenly bill claim to the wrong payer/ insurance but the primary insurance is another one. Actions First, we need to verify the status of the claim. This can be done by checking the

Date of service precedes the date of birth. Description This denial occurs when the date of service (DOS) on claim is earlier than the date of birth (DOB). It is not practically possible in real life, and most often this denial occurs due to an error—either in entering the date of service (DOS) or date

This procedure is not paid separately. Description There are certain procedures that cannot be billed alone and require a primary procedure code for reimbursement. If the procedure is billed without the primary procedure, or if the wrong primary procedure is used, this denial is received. Actions First, we need to verify the status of the

Payment made to patient, insured or responsible party. Description This denial mostly occurs when the patient has not signed the Assignment of Benefits (AOB). An Assignment of Benefits (AOB) is an agreement between the member and the insurance company that allows the insurance to pay the provider directly for the patient’s healthcare services. Actions First,

Procedure code was invalid on the date of service. Description This denial occurs when the insurance considers the procedure 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

Payer deems the submitted information does not support this level of service. Description This denial mostly occurs due to coding issues (medical necessity). Sometimes, reaching the maximum benefits for a service may also cause this denial. Sometimes, this denial may also occur if the insurance requires medical records to support the service. Actions First, we