Common claim denial types, and how to appeal each one
Most denials trace back to a handful of recurring reasons. Here's what each one means, the code behind it, and what actually overturns it. Pick the denial you're fighting.
Modifier 25
A Modifier 25 denial happens when you bill a significant, separately identifiable E/M service on the same day as a procedure, and the payer decides the E/M wasn't separate and bundles it into the procedure.
How to appeal it →Medical Necessity
A medical necessity denial means the payer decided the service wasn't medically necessary for the patient under its coverage policy, even though it was performed and documented.
How to appeal it →Timely Filing
A timely filing denial means the claim was received after the payer's filing deadline. It's the denial practices most often write off, and the one most often recoverable with proof.
How to appeal it →Prior Authorization
A prior-authorization denial means the payer says the required pre-approval wasn't obtained before the service. It's common, and a large share are recoverable.
How to appeal it →Bundling / NCCI Edits
A bundling denial means the payer applied an NCCI edit and folded one procedure into another, paying only the primary code even though both services were performed.
How to appeal it →Missing or Invalid Information
This denial means the claim is missing or has invalid information the payer needs to adjudicate it, from a member ID to a required modifier or referring provider.
How to appeal it →Coordination of Benefits
A coordination-of-benefits (COB) denial means the payer believes another plan is primary, or the patient's COB information is out of date, so it won't pay until the order is resolved.
How to appeal it →Non-Covered Service
A non-covered denial means the payer says the service isn't a covered benefit under the patient's plan. Some are truly non-covered; many are mis-categorized or mis-coded.
How to appeal it →Duplicate Claim
A duplicate denial means the payer thinks this claim or line was already submitted. Often it's a true duplicate, but frequently it's a distinct service the payer mis-flagged.
How to appeal it →Experimental / Investigational
This denial means the payer considers the service experimental or investigational under its medical policy, so it won't cover it, even when it's the appropriate care.
How to appeal it →Not sure which denials are recoverable?
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