In this week’s Video Review, it describes the 10 Most Common Reasons for a Denied Claim. Of
the 10 most common reasons for a denied claim: (1) What do you think the number one reason
is for a denied claim and why? (2) Which one reason is the most easily prevented and why?
1 PAGE DOUBLE SPACE ARIAL FONY (NO FORMATTING NECASSARY)
We are now going to review the top 10 most popular reasons that a health insurance claim
(1) Incorrect patient’s information (insurance ID# , date of birth): If you are submitting
electronic claims, AVOID entering patient’s insurance number with characters like an
asterisk (*) and dash (-) in between the alphanumeric numbers because these
characters can be recognize by electronic as unrecognizable. Just check on this issue
with the clearinghouse or your service provider. Always make a copy of your patient’s
primary & secondary insurance card on file (copy front and back!). Make sure to get a
copy of their new card (if there is a change).
(2) Patient’s non-coverage or terminated coverage at the time of service: That is why, it is
very important that you check on your patient’s benefits and eligibility before see the
patient. When you don’t verify in advance, you run the risk not receiving payment for
the service rendered to the patient.
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)— be careful also with
your secondary code! Claims may be denied even if the problem was just because of
the secondary CPT/ICD9 code: Discuss solving the coding error rather than how much
you want to get reimbursed. Most of the insurance companies will help you with codes
(in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th
digit. Be nice with the claims department! Also, under no circumstances can you
authorize a code change UNLESS you are the coder. Stay confined within the
parameters of your job description even though you may be aware of the necessary
(4) Incorrect use of modifiers! (be careful with bilateral procedures!, modifiers for
professional and technical component, modifiers for multiple procedures, postoperative
(5) No precertification or preauthorization obtained (if required): It is so hard to file an
appeal when the claim or service was non-pre-certified. Avoid it from happening!
(6) No referral on file (if required) Note: HMOs always requires a referral! (remember
(7) The patient has other primary insurance or the patient’s claim is for workman’s comp
or auto accident claim! It is the responsibility of your front desk staff to get all the
necessary information before the patient can be seen. Remember that if this is a
workman’s comp or an auto accident claim, you need a claim number and the adjustor’s
name. Services are always preauthorized!
(8) Claim requires documentation & notes to support medical necessity A well
documented medical records is a good practice!
(9) Claim requires referring physician’s info to include a NPI or national provider
(10) Untimely filing: This means that the claim was received by the insurance company
past their allotted time limit for submission. Unfortunately most of the insurances does not
accept your billing records on your office computer that shows that date(s) you billed the
insurance! If you are submitting claims by electronic, make sure you generate transmission
reports/receipts. Your reports must read “accepted” and not “rejected”. File all these
transmittal reports/ and receipts and a very safe place! If you are sending claims by paper
or postal mail, it is a good idea to send your claims as certified mail with tracking number,
keep your receipts!
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