When Do Claims Get Denied

When Do Claims Get Denied
14th November 2019 No Comments Blog admin

If you understand the major reasons as to why insurers deny medical claims, it can help you reduce the number of denials your treatment center receives. 

Foremost among them is Incorrect Patient Identifier Information. A medical claim must be filed with correct patient identifier information. If the information is not relevant, the health insurance plan will not be able to identify the patient for making a payment. It should also be ensured that the claim information is applied to the proper patient health insurance account.

Among some common mistakes that lead to a claim being denied is inaccurate patient identifier information.

They may happen in the following cases:

1. The patient or subscriber’s name is not spelled correctly.

2. The date of birth of the subscriber or patient on the claim is at variance with the date of birth in the system of the health insurance plan.

3. Either the subscriber number is absent in the claim or invalid.

4. Either the subscriber group number is absent or invalid.

If insurance benefits are verified before services are rendered, the treatment center can alert in case the patient’s insurance coverage has expired. To avoid such instances, you get the latest insurance information or determine the patient as a self-pay.

Insurance payers will most likely deny services that a patient has been provided if they require prior authorization. The provider, in this case, may try to obtain a retro-authorization within 24 to 72 hours after the services have been provided based on the insurance payers’ guidelines.

In certain health insurance plans, medical records may be requested when the claim needs further documentation for deciding the claim.

The denial of a claim on the basis of coordination of benefit may occur when another insurance is primary, EOB (estimate of benefits) is missing, and there is a failure on the part of the member to update insurer with other insurance information. The term, coordination of benefits, is used in cases when patients have two or more health insurance plans. Some rules decide which health insurance plan is applicable to pay primary, secondary or tertiary. There are several standard procedures to determine the order in which the medical office needs to bill each health insurance plan.

If medical claims have to be processed accurately, standard codes are in place to classify services and procedures in a system of coding, known as the HCPCS (Healthcare Common Procedure Coding System). Claimants must ensure their medical coders are abreast of HCPCS codes. Alterations to HCPCS codes are revised periodically because while new codes are being developed for new procedures and current codes are being amended or discarded.

Providers must be conscious of punctually filing deadlines for each insurance carrier. For more information, contact us at  888-CLAIM02 (252-4602) or email us at  info@claimpathsolutions.com


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