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The most common reasons medical claims are denied

Denying a medical bill impacts a doctor’s practice and cash flow. Lowering your claim denial rate can increase your practice’s profitability and reduce administrative costs. To resolve bill denial issues, it’s important to understand the most common reasons for bill denials. Learn about the most common reasons medical claims are denied.

Incorrect Patient Identification Information

Patient Identification Information is the most important information for submitting a medical claim, including accurate patient identification information, and is the most important information for the health insurance company to identify the patient’s health insurance plan for payment. will help you find it.

Most claims denied due to inaccurate patient identification information include:

No Referrals on File No

Most insurance companies accept referrals. Physicians should not provide services if the patient has not received a referral from their primary care physician. In these cases, if a claim is submitted before a GP referral, the claim will be rejected.

A claim was submitted after the insurance company's deadline

If a claim is not submitted by the insurance company’s deadline, the claim will be denied. Be aware of the Timely Filing Deadline (TFL). Here are some examples of timely submission deadlines.

United Health Care

Timely submission deadlines are specified in the provider agreement.

Aetna

Physician: Claims must be submitted within 90 days from the date the service was received. Hospital: The application must be submitted within one year from the date of birth.

Tricare

Claims must be filed within one year from date of service.

CPT code or HCPCS code is missing or invalid

In the medical billing process, the healthcare industry uses standard codes to indicate services and procedures. This coding is called Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System “HCPCS.” These codes change frequently. Therefore, it is important to ensure that medical codes are kept up to date and compliant with revised codes.

Lack of Documentation to Justify Necessity

If the payer is not satisfied with the medical necessity of the procedure, the claim will be denied. In these cases, additional documentation may be required to determine your claim. For this purpose, the medical record includes the following items:
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