Health insurance can be tricky to navigate for everyone involved. If your information isn’t exactly correct when you file claims for your patients, the rules involved will cause the claims to be denied and lead to lost time, the patient’s frustration, and extra work for insurance billing adjusters. Here are three of the most common reasons why claims get rejected. Remember, if it’s rejected it means when it got to the payer their internal EDI department couldn’t review the bill because there was incorrect information. If it gets denied by the payer then it means it got to them, but they are denying payment for a myriad of reasons. If you get a rejection letter, make sure you correct the information and send it again.
Each patient has several pieces of identifying information that his or her insurance company uses to determine claim eligibility. The first and last name has to be spelled correctly and entered into the correct fields on the claim form. Some companies have the last name first.
Next, you need to have4 the patient’s policy number correct. Even an error of a single digit will return incorrect information. The same goes for the group prefix. For example, if HWW is mistyped as HEW, it won’t match what’s on the patient’s insurance ID card. Similarly, the patient’s date of birth must be correct.
While these seem like simple and obvious errors, they are vital to monitor.
Insurance companies use billing codes on claims to determine patient eligibility. The most important codes are CPT and ICD-10 codes, which are for procedure and diagnosis respectively, but you’ll also have to know about the type of service and place of service. The diagnosis code influences whether a service is considered routine or non-routine.
For example, if a routine physician visit comes with an ICD-10 code that translates to a headache, the claim will be treated as non-routine and potentially not be covered under the patient’s plan. If your team needs reference materials or review services, Secure Healthcare Services can get them the resources to code insurance claims accurately the first time they’re filed.
Every doctor who takes a contract with an insurance company must be properly credentialed. All board licenses, state documentation, tax information, and other data must have been submitted to the insurance provider and finalized prior to claims being submitted. Otherwise, it’s likely that the doctor will not show up in the insurance company’s profile, leading to the claim being filed as out of network for the patient.
For some insurance companies that work nationally, you first need to submit the claim to the insurance in the state where your practice resides, who will then forward it to home plan. For example, if your practice is in California and the patient’s insurance is headquartered in Rhode Island, you need to send the claim first to the California branch, who will then forward it to the Rhode Island branch.
These are just a few reasons why health insurance claims keep getting rejected by insurance. It’s vital to ensure all information is correct and that the patient’s policy covers the procedure that’s about to occur.
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