(1) Incorrect patient’s information (insurance ID# , date of birth):
numbers because these characters can be recognize by electronic as
unrecognizable.
unrecognizable.
Always make a copy of your patient's primary & secondary insurance card on file
(copy front and back!). Make sure to get a copy of their new card (if there is a
change).
(2) Patient’s non-coverage or terminated coverage at the time of service
may also be the reason of denial:
That is why, it is very important that you check on your patient’s benefits and
eligibility before see the patient (unfortunately, I have seen practices who does not
check on benefits and eligibility on their patients so they end being not paid for the
service they rendered for the patient)
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be
careful also with your secondary code! Claims may be denied even if the problem
was just because of the secondary CPT/ICD9 code!
Again as I previously pointed out with my other articles on tracking your claims,
with this problem, discuss solving the coding error rather than how much you want
to get reimbursed. Most of the insurance companies will help you with codes (in
fairness!!) and they also inform you on outdated codes, or codes that requires a
5th digit.
(4) Incorrect use of modifiers! (be careful with bilateral procedures!, modifiers
for professional and technical component, modifiers for multiple procedures,
postoperative period, etc.)
(5) No precertification or preauthorization obtained (if required): It is so
hard to file an appeal when the claim or service was non-precertified. Avoid it from
happening!
(6) No referral on file (if required) Note: HMOs normally requires a referral!
(remember that!)
(7) The patient has other primary insurance or the patient’s claim is for
workman’s comp or auto accident claim!
It is the responsibility of your front desk staff to get all the necessary information
before the patient can be seen. Remember that if this is a workman’s comp or an
auto accident claim, you need a claim number and the adjustor’s name. Services
are normally always preauthorized and requires prior authorization!
(8) Claim requires documentation & notes to support medical necessity. A
well documented medical records is a good practice!
(9) Claim requires referring physician’s information
(10) Untimely filing - Unfortunately most of the insurances does not accept your
billing records on your office computer that shows that date(s) you billed the
insurance! They want a receipt from your electronic receipt or for postal mail,
obviously they want a receipt too! a tracking number maybe? certified letter
receipt?
If you are submitting claims by electronic, make sure you generate transmission
reports/receipts. Your reports must read "accepted" and not "rejected". File all
these transmittalreports/ and
receipts and a very safe place!
If you are sending claims by paper or postal mail, it is a good idea to send your
claims as certified mail with tracking number, keep your transmission receipts!!
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*** CPT codes and its descriptions are copyrights, owned, maintained and is a trademark of the
AMA (American Medical Association).
*** Always consult your CPT Code Book! and the NCCI Edits
*** Get more information on clinical guidelines and policies from your local CMS carriers and
from your third party payors
*** You can purchase CPT Code books and CPT Assistants issues from the AMA's Bookstore!
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