Medical billing denials and way to handle those with better understanding

1. Denial Series
Non covered
Services

2. Non covered
 Non covered service is a service, item, or
supply for which reimbursement is not
available

3. Non covered
Bill the patient Get the policy /Contract Copy
Write off

4. Non covered
 The main reason for the denial is that the
service provided may not be listed in the
patient of the providers contract.
 The other reason may be the provider is out
of network and that the patient wouldn’t
have out of network benefits.
 The claim can also be denied as non
covered as the service is rendered in an
inappropriate place of service.

5. Non covered
 Check the patients history to see if the service
denied is already paid.
 Check the patient eligibility and see if this is a
covered benefits.
 Also check the provider grid to see if this is a
par or non par provider as the patient might not
have out of network benefits.
 Also check and see if the denial is based on
the place of service as certain codes will be
covered only in a specific POS.

6. Information
 Denial Date & Claim #
 Is it as per patient plan/ Provider contract?
 If it is provider contract where can I get the
policy or can you fax the same.
 If it is as per patient plan, can we bill the
patient.
 Call ref#

7. Denied for EOB

8. Denied for EOB
 Check if the claim is paid by the primary
 If yes, get the fax #/ Mailing address & send
the EOB.
 If it is cross over claim check why it is not
reached the secondary insurance

9. Primary requesting - EOB
 If we did not received the payment from any
of the insurance
 When this is insurance became secondary?
 Do they have any info about the primary?
 If yes file the claim to the correct primary.
 Check with the related paid claims.
 Bill the patient to update the insurance info.

10. Denied for COB

11. COB
 Co ordination of Benefits
 Patient need to update every year/whenever
there is a change
 Check when they send the letter to the
patient
 If it is >30 days ask them to send one more
letter to patient.

12. COB
 Check the denial date if it is > more than 30
days check if they received any update from
the patient
 If no response, Bill the patient.

13. Denied - Capitation

14. Capitation
 Get the details from which date Provider is
under capitation contract
 Check if they paid the Capitation amount for
this month
 Request to send duplicate copy of
Capitation Roster.
 If the denial is incorrect send this claim for
reprocess

15. Capitation
 If denial is received from Medicaid
 Check if patient is eligible with Medicaid
MCO.
 If the patient is active with Medicaid MCO
file the claim to MCO.

16. Denied for Referral

17. Denied for Referral
 Check the patient Insurance plan – HMO
 Check in software
 Check in website
 Confirm with the insurance if POS is IP.
 Filter by Admit date to confirm if any other
claims paid with Referral.
 Get the contact # of PCP.
 Call the PCP and get the referral

18. Denied – Referring Provider info

19. Referring Provider
 If they denied for Referring provider NPI or
any other provider related info, check in
Dictionary.
 If No referring Provider in the claim check
Charge ticket or super bill
 Check in Medical records
 Send to billing to add referring provider
details and refile the claim.

20. Incorrect DX/CPT/Modifier

21. Incorrect DX
 Check which DX billed and check in Code
correct/Encoder is it valid or Missing any
digits.
 Confirm if the insurance also received the
same code or any truncations
 If DX is not correct send to Coding for
correction
 If it is incorrect denial send back for
reprocessing

22. Incorrect CPT
 Check CPT code and find when this was
deleted.
 If any HCPCS codes billed to insurance
other than Medicare can be denied
 Find alternate code and refile with corrected
CPT.
 If the denial is incorrect send for
reprocessing

23. Incorrect Modifier
 Check Modifier is the same in insurance
 Check which is the correct Modifier
 If it is correct send this for reprocess
 Or send to coding to change modifier
 Take global action on this

24. Paid to Patient

25. Paid to Patient
 Check if the provider is non par
 Check in claim form if box # 27 is not
checked
 Bill the patient for entire charge amount
 If the provider is par, send this for reprocess
 Ask them to recoup the amount from patient
and pay to the provider

26. Denied for Pre Existing Condition

27. Pre Existing Condition
 Check the Effective date and denial date
 If it is > 6 months denial is incorrect
 If it is less than 6 months
 If insurance require info from patient/
Provider
 If from the patient bill the patient

28. Pre Existing Condition
 If it is from provider
 Check when they send PEC Questionnaire
to the provider
 Ask them to send the form by fax
 Send this to provider to get it signed & send
to insurance.
 If they require medical records for 6 months
attach the same with Questionnaire

29. Pre Existing Condition
 If our first Date of Service is less than 6
months
 Bill the patient for medical records since this
need to be collected from Other Provider

30. Primary Paid Maximum

31. Primary Paid Maximum
 Check the secondary allowed amount for
this particular CPT code
 Confirm the allowed amount is less than the
primary allowed amount
 Check the insurance
 If it is commercial – Bill the patient
 If it is medicaid/Medicare – Adjust the
Balance