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10 Common Reasons Why Medical Claims were being Denied and your Action Plan


(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 may also be the reason of denial That is why, it is very important that you check on your patient�s benefits and eligibility before see the patient (unfortunately, I have seen practices who does not check on benefits and eligibility on their patients so they end being not paid for the service they 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(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful also with your secondary code!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! Again as I previously pointed out with my other articles on tracking your claims, with this problem, 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 and they also inform you on outdated codes, or codes that requires a 5th digit.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! (at least you try!)

(4) Incorrect use of modifiers! (be careful with bilateral procedures!, modifiers for professional and technical component, modifiers for multiple procedures, postoperative period, etc.)

(5) No precertification or preauthorization obtained (if required) It is so hard to file an appeal when the claim or service was non-precertified. Avoid it from happening!

(6) No referral on file (if required) Note: HMOs always requires a referral! (remember that!)

(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 (with UPIN ofcourse!-this will be soon replaced by an NPI or the National Provider Identification number)

(10) Untimely filing Unfortunately most of the insurances does not accept your billing records on your office computer that shows that date(s) you billed the insurance! They want a receipt from your electronic receipt or for postal mail, obviously they want a receipt too! a tracking number maybe? certified letter receipt? 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!!

Submitted by:

Pinky Mcbanon

Pinky Mcbanon is an experienced Medical Biller and Coder based in New York. A graduate of Bachelor Science in Computer Engineering. A Medical Practice Billing Consultant. She shares her expertise and knowledge with http://www.medclaimsplus.com.

Read more about the author as she share her knowledge and expertise in her field by visiting her website at http://www.justmypassion.com





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