Eligibility and Coverage Denials
• Example: The patient is not eligible for coverage on the date of service.
• Cause: Verification of coverage wasn't done, or insurance information is outdated.
• Resolution: Confirm eligibility with the insurer before submitting claims, and update patient
records regularly.
Authorization or Pre-Certification Denials
• Example: Services provided require prior authorization, but authorization was not obtained.
• Cause: The provider did not get the necessary pre-approval for a procedure or service.
• Resolution: Ensure that authorization requirements are reviewed, and approvals are obtained
before treatment.
Medical Necessity Denials
• Example: The service is deemed not medically necessary based on insurance guidelines.
• Cause: The diagnosis or procedure code submitted doesn’t justify the necessity for treatment.
• Resolution: Review and understand payer-specific medical necessity guidelines, and adjust
documentation to support claims.
Duplicate Claim Denials
• Example: Submitting the same claim multiple times.
• Cause: Claims are resubmitted without any change in response to a pending or denied status.
• Resolution: Track claims carefully, and resubmit only if necessary with adjustments or
clarifications.
Coding Errors (Incorrect or Incomplete Codes)
• Example: Errors in procedure or diagnosis codes (e.g., incorrect CPT or ICD-10 codes).
• Cause: Coding errors or omissions in the claim.
• Resolution: Verify codes with the medical coding team, and use automated tools or software to
minimize errors.
Coordination of Benefits (COB) Issues
• Example: Insurance has not determined the correct primary payer.
• Cause: Multiple insurers are involved, and COB isn’t properly coordinated.
• Resolution: Confirm which insurer is primary, secondary, etc., and communicate this clearly on
claims.
Claim Timeliness (Late Filing)
• Example: The claim was submitted after the insurer’s deadline.
• Cause: Delays in submission, often due to lack of proper follow-up.
• Resolution: Familiarize with payer deadlines and set up reminders for timely submissions.
Invalid or Missing Information
• Example: Missing patient details, provider NPI, or insurance ID number.
• Cause: Claims submitted with incomplete information.
• Resolution: Double-check all required fields on the claim form, and use automated claim checks
if available.
Bundling and Unbundling Issues
• Example: Services are bundled by the insurer but submitted separately.
• Cause: Unbundling procedures or failing to recognize bundled service rules.
• Resolution: Understand bundling policies for each insurer to properly code bundled services.
Place of Service Mismatch
• Example: The place of service code does not match the service provided.
• Cause: Incorrect place of service code submitted with the claim.
• Resolution: Verify that place of service codes align with the type and location of service
provided.
