The document outlines the top eight reasons for claim denials in medical billing, including issues such as claims not on file, invalid codes, and lack of authorization. It details the actions taken by the billing office to address these issues and specifies the responsibilities of both patients and providers. Additionally, it provides statistical data on denial cases and amounts charged and received, emphasizing the importance of effective denial management in minimizing lost revenue.

1. Top 8 Denial Reasons

2. Top 8 Denial Reasons
Action that is taken by
Classification Description the Medical Billing Star
In most cases the claims sent out to local insurance companies
by paper are the ones that need to be resubmitted as the
Claim not on file Insurance companies do not have the initial claims that are
sent. billing office ensures that all unpaid claims are called and Medical Billing Star already follows up on these
(Medical Billing Star checked with the respective insurance companies within their claims and ensures that the claims are resent
responsibility) filing limits. within the filing limits
The billing office ensures that the primary
Additional Information insurance companies EOB is sent out to the
Insurance companies require separate documentation like, secondary Insurance company. All other
(Provider/Patient Primary insurance company’s explanation of benefits, the requests for further information is forwarded to
2 responsibility) coordination of benefits from the patient, accident details etc . the Patients by statements
Patient responsibility This is normally the case when patient is billed for the Medical Billing Star ensures that all payment
payments as they lack an insurance plan and these claims are statements are sent across to the patients in a
3 (Patient responsibility) kept open until we receive payments from the patients timely manner
Medical Billing Star ensures that all payment
statements are sent across to the patients with
Patient not valid This is normally the case when the patient has a insurance an explanation that their plan has been
plan which has termed before his date of service and so the terminated and that they would have to get back
4 (Provider responsibility) payment statement is sent out to the patient for payment with valid insurance information
The provider for certain procedures gets an approval or
authorization number from the insurance company before they Medical Billing Star gets back to the provider for
go ahead. In most cases the authorization number is not information about the authorization number that
No Authorization/Referral# mentioned by the provider’s office in the documents sent over they should have received. If they get the
to the billing office. Insurance companies deny claims for these required info, the claim is resubmitted to the
5 (Provider responsibility) certain procedures on these grounds Insurance company

3. Top Reasons …
Insurance companies have an approved list of
procedure/diagnosis combinations that they would pay Medical billing star already follows up on the
Invalid CPT code/ Dx for. Medical billing star maintains a database of the these claims and ensures that CPT/ICD
code approved combinations by different insurance codes are corrected as per the respective
companies. Our experienced coders ensure that the insurance companies and resubmitted within
(Medicalbillingstar highest paying approved combination of procedure and the filing limits
responsibility) diagnosis codes are used to ensure maximum payment
Mutually Inclusive Modifiers are required for certain claims to be able to tell Medicalbillingstar already follows up on
the insurance company that the procedure billed for is a these claims and ensures that the necessary
revaluation based on a previously billed procedure code. modifiers are included and the claim is
(Medicalbillingstar These are reworked by the billing offices and resubmitted within the filing limits
responsibility) resubmitted within the filing limits
Medicalbillingstar ensures that all payment
Services not covered
This is when the patients insurance does not cover the statements are sent across to the patients
(Patient/Insurance procedure performed by the doctor and in most cases with an explanation that the services that
company’s the payment statement is sent out to the Patient were charged to the insurance company are
responsibility) not covered for their plan

4. Over a 5 month period with our existing clients.
Sl No Categories # of issues Charged amount Amount Received
1 Claim not on file 205 14284.8 5713.9
2 Invalid CPT code/ Dx code 17 4196.8 1678.7
3 Mutually Inclusive 16 1229.3 491.7
4 Additional Information 200 24614.3 9845.7
5 Patient responsibility 96 10438.7 4175.5
6 Services not covered 36 9610.9 3844.3
7 Patient not valid 61 3054.9 1222.0
8 No Authorization/Referral# 49 6407.3 2562.9
680 73837.0 29534.8
*approximate values, based on 40% of the charged values

5. Denial Reasons - # of issues
49, 7%
61, 9%
205, 31%
36, 5%
96, 14%
17, 3%
16, 2%
200, 29%
Claim not on file Invalid CPT code/ Dx code Mutually Inclusive Additional Information
Patient responsibility Services not covered Patient not valid No Authorization/Referral#

6. Denial Reasons – Amount Received
2562.9, 9%
5713.9, 19%
1222.0, 4%
3844.3, 13%
1678.7, 6%
491.7, 2%
4175.5, 14%
9845.7, 33%
Claim not on file Invalid CPT code/ Dx code Mutually Inclusive Additional Information
Patient responsibility Services not covered Patient not valid No Authorization/Referral#

7. Medicalbillingstar also maintains an internal database of rejected
and underpaid claims of various carriers to serve as an expeditious
source of reference for similar cases in the future. This drastically
cuts down our denial management time-frame and puts the money
where the mouth is, i.e. the physician’s pockets