A denied status indicates that the insurance payer processed the claim, but denied payment. This differs from rejected claims or scrub errors, because the denied claim was successfully processed by the payer, but reimbursement was not issued.
In this guide, we’ll cover:
Important: The quickest way to resolve a denial is to contact the payer directly and request instructions for correcting the claim.
Issues that can lead to denials
Claims are typically denied if they include:
- Invalid or missing CPT codes
- Invalid or missing modifiers
- Invalid or missing provider details
- Non-covered services
Claims can also be denied if they’re submitted outside of the payer’s timely filing window, or if the client’s insurance plan is no longer active.
Claim regulations are set by payers. Contact the payer directly if you’re unsure of their submission requirements.
What to do when a claim is denied
The language used in denials comes directly from the payer, and the reason listed may not always be explicit. Payers may also have different requirements for how a denied claim should be resubmitted. Because of this, it’s recommended to contact the payer if you have questions about the cause of the denial or how to correct it.
When contacting the payer, provide them:
- The client’s member ID
- The date(s) of service
- The total billed amount
- This is listed in box 28
This information helps the representative locate the claim in their system.
To ensure accurate guidance, clarify that the claim was submitted electronically. Electronic claim filing requirements differ from paper submissions, and the representative may not immediately know which method was used.
Also verify your billing information during the call. You may be registered with payers as an Individual provider or as an Organization. Confirm whether the payer has your Billing Provider Information listed as:
- Type 1 (Individual) NPI and SSN or Tax ID/EIN
- Type 2 (Organization) NPI and Tax ID or EIN
If the denial is due to missing or invalid provider details, ask the payer what “Billing provider NPI and Tax ID” combination they have on file so you can determine what should be used for electronic claim submissions.
If billing under a group NPI, verify that the rendering NPI in box 24 is approved to bill under the Billing Provider NPI in box 33.
Tip: When contacting a payer, note the representative’s name, phone number dialed, and call reference number.
Once the payer confirms what needs to be corrected, they’ll typically request a corrected claim. For details on this process, see Submitting a corrected claim.