Top 13 Reasons For Claim Denials

Denied claims are one of physicians’ chief complaints when it comes to dealing with payers.

To a certain extent, every practice deals with claim denials. It’s those practices that eliminate the most common reasons that experience a smoother revenue cycle and find greater financial success.

Here are the 13 most common reasons for why claims are denied.

1. A duplicate claim was submitted when a practice hasn’t received reimbursement
2. The patient isn’t eligible for services because his or her health plan coverage ended, and the patient hasn’t shown proof of new insurance
3. The patient hasn’t met the deductible for the calendar year
4. Some services are bundled. For example, laboratory profiles with multiple tests don’t qualify for separate reimbursements, or an all-encompassing rate covers the minor procedure and the pre- and post- procedure visits. The provider receives one combined payment.
5. The benefit has been exceeded, such as the maximum allowed number of physical therapy visits covered by the health plan within a calendar year.
6. The claim form is missing a modifier or modifiers, or the modifier(s) are invalid for the procedure code (as in the case of bilateral codes billed on both sides.)
7. As inconsistent place of service is marked on the claim form, such as an inpatient procedure billed in an outpatient setting
8. A particular service isn’t covered under the plans benefits, or there appears to be a lack of medical necessity. In another example, there could a mismatch between the actual diagnosis and the service performed
9. The client is deficient in certain information. It may be missing prior authorization or the effective period of time within which the pre-approved service must be provided for reimbursement to occur
10. There is a coding or data error with mismatched totals or mutually exclusive codes
11. It may be necessary to coordinate benefits when dual coverage issues arise, such as with secondary insurance of workers compensation
12. The filing deadline has passed. If a claim isn’t submitted to the insurer within the permitted time frame, it is likely to be rejected. The limit to file can be as short as 90 days from the date of service
    Errors or typos were made while collecting pertinent information from the patient or during the data entry process for a claim.