1). A duplicate claim was submitted when a practice hasn’t received reimbursement.
2). The patient isn’t eligible for services because their health plan coverage ended, and the patient hasn’t shown proof of new insurance.
3). The patient hasn’t met his/her deductible for the year.
4). Some services are bundled. For example, laboratory profiles with multiple tests don’t qualify for separate reimbursements, or an all-encompassing rate covers the minor procedures and the pre- and post- procedure visits. The provider receives one combined payment.
5). The benefit has been exceeded, such as the maximum allowed number of physical therapy visits covered by the health plan within a calendar year.
6). The claim form is missing a modifier, or modifier(s) are invalid for the procedure code (as in the case of bilateral codes billed on both sides).
7). An inconsistent place of service is marked on the claim form, such as an impatient procedure billed in an outpatient setting.
8). A particular service isn’t covered under the plan’s benefits, or there appears to be a lack of medical necessity. In another example, there could be a mismatch between the actual diagnosis and the service performed.
9). The claim is deficient in certain information. It may be missing prior authorization or the effective period within which the pre-approved service must be provided for the reimbursement to occur.
10). There is a coding data error with mismatched totals or mutually exclusive codes.
11). It may be necessary to coordinate benefits when dual coverage issues arise, such as with secondary insurance or worker’s compensation.
12). The filing deadline has passed. If a claim isn’t submitted to the insurer within the permitted time frame, it is likely to be rejected. The limit to file can be as short as 90 days from the date of service.
13). Errors or typos were made while collecting pertinent information from the patient or during the data entry process for a claim.