2. Understand the denial reason - was it a coding issue, or a coverage issue?
3. Get specific info on what coverage/billing guideline is being referenced, and how it can be resolved.
4. Contact the patient when necessary, and give them a specific time period to take care of things that they need to before billing them.
5. Submit a corrected claim, when applicable.
In order to correct a denial, it's critical that they understand it. It sounds simple, but figuring out where exactly something went wrong on a claim is harder than it seems. They can't be afraid to call the insurer and ask questions, and they need to learn how to tell when the answer they're getting is incorrect.
Common coding denials:
Incorrect CPT code/Modifier combination
Invalid ICD-9/CPT/HCPCS for the DOS, patient's gender or age
Bundling issues (E/M needs a -25 mod, labs/procedures need a -59 mod, etc.)
Incorrect # of units billed
Billing/Claim format denials:
Patient's relationship code to subscriber incorrect (self, parent, child, etc.)
Patient's info entered incorrectly (Name, DOB, policy #, group #)
Subscriber's SSN missing/wrong
Accident/Auto/Work Injury field is filled out incorrectly
Onset dates (boxes 14/15 on CMS-1500) not completed
Provider info not billed correctly or Provider not contracted with network
Billed the wrong insurance as primary
Didn't submit the primary EOB to secondary
Service doesn't meet coverage guidelines/billing criteria
Policy not effective on DOS
Patient doesn't have benefits for the service [ever/for the Dx indicated]
Service is subject to a rider/pre-existing exclusion
Patient needs to give info to the insurer (Coordination of Benefits, Accident details, divorce decree, etc.)
Patient need to give you COB info, so you can file to the correct payer.
That's certainly not all of the reasons things deny, but it covers most. Hope that helps!
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join