Top 10 Reasons a Claim is Denied

The table below lists the top reasons why a claim is denied.

Claim Denial Considerations

Incorrect patient identifier information

Make sure that you enter the patient's demographic and payer information exactly as stated on the insurance card.

  • Patient name - If a patient's insurance card says Debra J. Smith but her driver's license says Debbie J Smith, if the claim is sent to the payer with the name Debbie J. Smith, the claim may be denied.
  • Date of birth is incorrect
  • Missing or invalid subscriber or insurance group number
Insurance benefits weren't verified correctly
  • Procedure was not covered or required prior authorization.
  • Patient's coverage terminated for the date of service.
  • Procedure requires a referral.
Requesting medical records Claims sent electronically cannot include chart notes and some payers, require chart notes to process the payment.

Coordination of benefits information needed

  • The primary EOB is required for a secondary claim.
  • Member has not updated payer with other insurance information.
  • Wrong insurance listed as primary.

Missing or invalid CPT Code or DX code

  • CPT code being used on the claim is not on the fee schedule.
  • Diagnosis code has not be selected.
  • Diagnosis code and/or CPT code used in invalid. The payer requires the service be billed as a different diagnosis or CPT code.
Timely filing The time between services rendered and when the claim was submitted is too long. Timely filing deadlines vary by payer.
Incorrect use of modifiers The wrong modifier was used for the service performed.
Denied for medical necessity The therapist has not proved the procedure is medically necessary. Better documentation is required.
Multiple services on the same day. If a patient receives services on 2 different body parts on the same day many payers will routinely deny the claim when it is initially sent and you will need to appeal.
Incorrect payer Workers comp claim sent to a commercial payer.

Related Topics:

Troubleshoot Not Ready Claims

Lifecycle of a Claim

Click here to move×