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Reason for Denied Claims, insurance companies

One of our primary goals as an experienced medical billing company is to avoid denied and rejected claims. With that in mind, here are 10 of the most common reasons that we see for denied medical claims from insurance companies. This list is by no means inclusive, and only mentions some of the more common reasons.

[1] Late Claims:  Always pay attention to the timely filing limit or deadline. This can range from 3 months to one year depending on the insurance provider. If the claim is filed too late after the service is provided it will be denied and the medical service provider is not paid!

[2] Lost or Expired Claims:  Claims have to be entered into the insurance company’s system to be processed. If the claim is lost or “misplaced” — well refer above to reason number one.

[3] Wrong or Missing Billing Codes:  Incomplete, invalid, or missing ICD-10 and CPT codes will result in payment delays or the claim will be rejected. Mistakes on the superbill are costly.

[4] Credentialing: If healthcare professionals are not properly credentialed with that insurance provider, they will have a difficult time getting paid for any services they submit to that provider. Just because they are credentialed with one provider, does not mean that they are credentialed with other providers.

[5] Unauthorized claims:  Preauthorization is required for many medical services. If the services are provided without proper authorization the claims will be automatically rejected by the insurance provider.

[6] Two services are provided in one day:  Insurance companies may have a policy of paying for only one service per day. Whether the patient is authorized for 10 sessions or more, if they receive two sessions a day, the second claim will be denied. The proper use of modifiers will help in this situation, but medical practitioners need to be careful.

[7] All authorized sessions have been used:  Sometimes authorization is granted for a certain number of appointments or services. Additional sessions or services will not be paid without a new authorization.

[8] A proper referral from a physician was not obtained:  Some insurance policies require prior authorization and referral from the primary care provider (PCP) or similar medical specialist. If healthcare services are provided without a referral, that medical claim will likely be rejected.

[9] The prior authorization expired:  Prior authorizations may have an expiration date and sometimes they expire in as little as 30 days. If the services are not provided within this approved time frame, the claim is denied.

[10] Patient’s health insurance has changed:  When patients change their insurance policy they need to obtain a new preauthorization and verify that their healthcare practitioner accepts their new insurance, as well as that their medical provider is in the network. Any claim submitted using a patient’s canceled insurance policy will naturally be denied.

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Reason for Denied Claims, Insurance Companies