Pediatric Coding Alert

Question: When we know that the carrier has made a mistake in denying one of our claims, can we simply resend the original claim again, or will the carrier just deny it again?

Codify Subscriber

Answer: Although simply resending a claim that the carrier erroneously denied sounds like a logical, easy answer, in the end it might cost you more time and effort. The carrier denied the claim for a particular reason during the first round of submission. If you don’t address that reason now, your claim will likely return to you as a denial again. Additionally, once a payer has processed a claim for a date of service, they will detect the duplication in the date of service and CPT® code(s) and deny the service(s) as a duplicate claim.

Possibilities: Many things can go wrong that will result in an erroneous denial. Problems with patient pre-authorization, physician credentials with the carrier, an oversight on your part on the claim, or problems with the carrier’s processing systems are just a few things that could all cause an incorrect denial.

Good practice: Rather than automatically resending the claim, contact your carrier representative. Discuss the denial with the representative, and figure out why the carrier denied the claim. A short phone call could save you much more time in the long run. Usually a corrected claim and an appeal need to be sent, explaining why the claim should be paid, what coding rules were utilized for the claim, and the documentation in order to be paid on a claim that was improperly denied or an error took place on the practice’s end on submission of the claim.