A denied status indicates that the insurance payer processed the claim, but denied payment. These are different from rejected claims or scrub errors because the denied claim was successfully processed by the payer, but due to an issue on the claim, they didn’t provide reimbursement.
In this guide, well cover:
Important: The quickest way to resolve a denial is to contact the payer directly, and request instructions for correcting the claim. For more information, see What to do when a claim is denied below.
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
- Noncovered services
Claims can also be denied if the claim is submitted outside of the payer’s timely filing window, or if the client’s insurance plan is no longer active.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 a payer directly if you’re not sure what their requirements are for submitting this information.
Locating a denial in your account
If you’re not enrolled to receive electronic Payment Reports (ERAs), claim denials won’t be posted in your SimplePractice account. Payers will instead mail you a physical Explanation of Benefits (EOB) outlining the reason for denial. Some payers will post their own version of an electronic Payment Report on their online portal.
Tip: We recommend enrolling to receive electronic Payment Reports so that you can receive claim updates in your SimplePractice account. For more information, see How do I submit an enrollment to file claims or receive Payment Reports?
If you’re already enrolled to receive Payment Reports, you’ll receive an email notifying you that a claim has been denied. Clicking View Claim in this email will take you to the claim’s Payment Report, where you can view the denial.
You can also locate the denial by following these steps:
- Navigate to Insurance > Claims
- Use the Denied filter
- You can also filter by date, insurance payer, and the client
- Open the claim
- Click Claim Details at the top of the claim
Scroll down to the Payment Report and hover your cursor over the ? icon.
Important: SimplePractice doesn’t receive any additional details beyond what’s included in the Payment Report.
What to do when a claim is denied
The language used in denials comes directly from the payer, and the reason listed won’t always be explicitly stated. Payers also have different requirements in regards to how a denied claim should be resubmitted. Because of this, it’s always recommended to contact a payer if you have questions about what caused the denial, or how to resubmit the claim.
When contacting the payer, provide them:
- The member ID of the client
- The date(s) of service
- The total billed amount
- This will be listed in box 28
Providing this information will help the representative locate the claim in their system.
To make sure the representative you’re working with can provide accurate information about how to correct the claim, explain that the claim was submitted electronically. Claim filing guidelines for electronic submissions differ from those used for paper claims, and it may not be clear on the representative’s end that the claim was submitted electronically.
It’s also important to verify your billing information when reaching out to a representative. You can be registered with insurance payers as an Individual provider, or as an Organization, and it’s important to clarify whether they have your Billing Provider Information listed as either:
- 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 representative what “Billing provider NPI and Tax ID” combination they have on file to clarify what should be provided on electronic claim submissions.
If billing under a group NPI, there are additional requirements for a proper claim submission. To make sure you've submitted the claim correctly, we recommend verifying if the rendering NPI listed in box 24 is approved for billing under the Billing Provider NPI listed in box 33.
Tip: When contacting a payer, it can be helpful to take note of the call details, such as the name of the representative, the phone number reached, and the call reference number.
Once the representative has clarified what needs to be corrected, they’ll typically request that you submit a corrected claim. For more information, see Submitting a corrected claim.