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10 Common Reasons Claims Get



They may seem simple, yet still account for a lot of denials Incorrect patient information (Insurance ID#, date of birth, SSN#, etc.): · Avoid entering patient insurance number with characters like asterisk (*) and dash (-) in between the alphanumeric numbers, because these characters cannot be recognized by electronic systems.

· Always make a copy of patient's primary and secondary cards (both


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No referral on file: · HMOs normally require a referral.


sides), and ask at registration if any change of insurance has occurred.

· Validate and correct patient demographic information through an ad-


Patient has other primary insurance or claim is for workers' comp or auto accident claim: · All necessary information must be obtained by the front desk PRIOR to the patient being seen. For workers' comp or auto accident claim, you need a claim number and the adjuster's name. Services almost always need pre-authorization. Further documentation and/or notes requested to support medical necessity:

· Every practice should strive to document, document and document. A


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dress checker product that will verify or change name, address, DOB, and SSN. This will also help reduce your mail return.

Patient's non-coverage or terminated coverage at time of service: · Verify patient's benefits and eligibility BEFORE rendering service. CPT / ICD9 Coding Issues: · Many practices use outdated coding books, which can be updated yearly and sometimes quarterly. There are several online resources as well as clearinghouse and practice management systems offering coding solutions. Incorrect use of modifiers: · Bilateral procedures, modifiers for professional and technical component, multiple procedures, and postoperative period are some examples.

No pre-certification or pre-authorization obtained:

· When you get it, document it. It is very hard to file an appeal when the

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well documented medical record will not only help you get paid, but protect you in the event of an audit or worse, litigation. An EMR can go a long way to helping with this.

Claim missing referring physician's information: · Keep track of the carriers that require this. UNTIMELY FILING: · If submitting claims electronically, make sure to generate transmission reports or receipts. Be sure the reports read "accepted" and not "rejected." Keep in a safe place. · For paper claims, you may choose to send as certified mail with a tracking number and keep your receipts.


This information was provided by Transworld Systems, an OSMA Preferred Partner. For more information about Transworld, please contact the OSMA at (800) 766-6762 or [email protected]

claim or service was not pre-certified.


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