What are the typical claim denial reasons?

The Claims Lifecycle AI API gives the user real-world advice on how to avoid rejected claims. The denial reason may apply to either a professional claim or an institutional claim. Some of the reasons given are simple goofs that should be easily remedied before a submission, such as making sure that medical documentation is provided with the claim.

  • Authorization / Pre-Certification - Required Authorization or Pre-Certification was not obtained, or was not correctly listed on claim. The provider does not have a current authorization to submit claims to the payer.
  • Avoidable Care - Service provided due to quality lapse of initial treatment.
  • Duplicate Claim/Service - The claim was previously filed, or the same service was listed more than once on the claim.
  • Medical Coding - Issue with CPT, ICD, DRG, qualifier or modifier code(s).
  • Medical Documentation Requested - The payer is requesting medical documentation to support the claim.
  • Medical Necessity - The payer states that the procedure, service, or level of care was not medically necessary. Payer may observe that an alternative treatment exists for the conditions described in the claim, which provides the same efficacy as the claim's described treatment, typically at a reduced cost to the payer or to the subscriber.
  • Missing or Invalid Claim Data - Required claim data is not present, invalid, or there is an inconsistency in dates or claim submitted for partial service.
  • Provider eligibility - The provider is not credentialed or eligible to perform the type of service, at the type of location or treat the type of condition.
  • Registration/Eligibility - There was an error in the patient’s registration information or the patient was not eligible for the payer or service.
  • Service not covered - The payer has determined that treatment for the condition is not covered due to pre-existing condition, or the timing or location of the service is determined to not be covered.
  • Untimely Filing - The claim was not submitted within the required time limit.
  • Other - Adjustment types that do not fit into one of the categories above.
  • Unknown - Unknown or invalid adjustments codes.

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