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What do I do if my claim is denied?

What do I do if my claim is denied?

A Denied status indicates that the payer processed the claim, but denied payment. This could be due to how information was entered on the claim, such as an invalid CPT code or a missing modifier. It may also be because the services aren't reimbursable based on your contract with the insurance company, or the client's insurance plan. 

If you’re enrolled to receive payment reports from this payer, you can view the denial reason by clicking Claim Details at the top of the denied claim. To display the denial reason, scroll down to the payment report and hover your cursor over the icon at the bottom of the report: 


SimplePractice doesn't receive any additional details beyond what's included in the payment report that you see. 

If you need additional clarification for the denied claim, please contact the payer directly and provide the member ID, date of service, and total billed amount to help the representative locate the claim in question. 

To make sure the representative you're working with can provide accurate information about how to correct the claim, you'll need to share some additional context. It's important to explain that the claim was submitted electronically. Claim filing guidelines for electronic claim submissions differ from those used for paper claims. For example, paper claims require a physical signature, whereas electronic claims don't. Instead, electronic claims are authenticated by a signature on file with the payer, as indicated by checking Box 31 of the claim submission. When a payer's representative pulls up a claim on their end, they won't see whether a claim was submitted electronically or by paper and may incorrectly assume that a signature is missing from Box 31. 

It's also important to verify your billing information when reaching out to a representative. You can register as an Individual provider or as an Organization with Insurance payers and it's important to clarify whether they have your set of 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. 

Please keep in mind that our clearinghouse doesn't receive any additional information regarding claim denials and can't provide further guidance on how to resolve denied claims. For the fastest resolution when it comes to claim denials, we always recommend working directly with the payer so they can clarify exactly what needs to be corrected before you resubmit. 

Tip: When you're ready to submit a corrected claim, you can refer to our guide on submitting corrected claims, which includes details on things to consider when submitting a corrected claim.

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