Recognize Common Denial Reasons
The most common denial remark codes due to registration errors are:
- Expenses incurred after coverage terminated
2 Expenses incurred during a lapse in coverage
3 Claim denied as patient cannot be identified as our insured
4 Claim/service not covered by this payer
5 Secondary payment cannot be considered without the identity of the primary payer
6 Service not a plan benefit, use of service code 510
7 Modifier inappropriate
8 Duplicate charge previously submitted
9 No authorization for services
10 Member not enrolled on date of service
There are steps you can take to avoid these types of denials and improve patient satisfaction.
How to Prevent the Denials
Collect the Right Information at the Right Time
Verifying eligibility prior to the appointment and then confirming this same information once the patient checks in can do wonders for your accounts receivable.
When a patient arrives, your registration staff should ask questions to retrieve the patient’s demographics and then verbally verify the information back to them.
Medicare beneficiaries with a Medicare Advantage plan are the most susceptible to an error in this questioning. If the registration staff asks, “Do you still have Medicare?” the patient is likely to say yes, but they could have recently changed from traditional fee-for-service (FFS) Medicare to a Medicare replacement plan.
In a 2019 WPS Government Health Administrators’ conference, the speaker said one of the most common denial remarks is “Claim not covered by this payer, you must send the claim to the correct payer/contractor.” This signals to the provider’s office that the patient does not have traditional FFS Medicare. It is also one of the easier denials to avoid, by simply confirming whether the patient has a Medicare replacement plan at the time of service.
Ask the Right Questions to Get the Answers You Need
Coordination of benefits (COB) issues can be the most time-consuming and costly to resolve. Often, the patient has to reach out to the insurance company and straighten out a COB issue.
It is not only essential that the insurance information is correct, but also the order in which it is sequenced on the claim. Medicare contractors provide us with the Medicare Secondary Payer (MSP) Questionnaire, which can be used by the front desk staff when there is more than one insurance for a Medicare patient. This question-naire helps identify the primary payer by asking questions related to the patient’s other insurance.
6. Resubmit the claim using service code 513 instead of 510.
7. Modifiers are not required for Marketplace, use rendering individual NPI.
8 Claim has already been processed. Allow 30 days for electronic and 45 days for paper submission.
9. Prior Authorization was lifted for outpatient therapy services on 2/1/14. All other services require prior authorization.
10 Check member eligibility on insurance web portal for specific date of service.
- Eligibility denials for many reason – “Eligibility alone accounts for nearly one third of all denials.
Do the insurance verification even before patient check in. Call the patient or ask for the insurance info when he makes the appointment. Call the payer or use the payer’s Web site to verify benefits. Keep a current copy of the patient’s insurance card in her medical record – a scanned, electronic file or a paper copy. This makes coverage and copay checks easy for the
front office staff.
- Not tagging right ICDS and Modifiers. Non covered charges.
Get to know about top used CPTs and find our NCD AND LCD guidelines for those CPTs. For Medicare insurance’s- Search NCD and or LCD at
www.cms.gov/mcd/search.asp?clickon=search
Get to know about MUE edits and maximum units for each procedure. Use 76 modifier if you want to report procedure more than 1. another important aspect is get to know about CCI Edit.
What is a CCI Edit?
** CCI quarterly puts out a list of code pairs that Medicare — and many private payers — follow for payment
** CCI edits list pairs of CPT and HCPCS codes that payers will not pay on when you bill them together.
** Apply to services for same provider, same beneficiary, on same date of service
- Missing/incomplete/invalid place of service.
Look to admission status to determine POS for services. Medicare restricts certain tests to hospital inpatients. Expect denials if you report tests in other locations.
