3rd-party payment denials of your claims:
info site :
- be sure that we have your
correct insurance coverage information for the date that
our services were rendered![submit
the correct info]
- lost claim gambit: payment never received...upon contacting
payer/insurance office, it is learned that the claim "must have been
lost...we have no record of receipt." This type of
mysterious disappearance is a very big problem (J. SCMA, 97:445,
- "APPLIED TO INSURANCE DEDUCTIBLE": they apply
part or all of your claim to your policy annual deductible (an
amount they have told you in the policy that you must pay each
year). With the possibly numerous providers submitting claims
for their services, you are the only one who can add up the deductibles
and be sure that the insurer doesn't overdo it and apply too
much. If they do, then it comes out of your pocket if you don't
- Service payment was denied because of improper or
nonsense codes or other info (incorrect, or absence
of, policy owner name, address, social security number,
etc.). These "demographic" inaccuracies are such a
huge problem that companies such as Search
America exist to help providers (not patients)
for a fee.
- wrong ICD-9 codes:
- wrong Pap smear codes ;
codes for other services wrong.
- wrong codes, one is exclusionary: coder used two
codes which are mutually exclusive (need to choose one
or the other & resubmit claim).
- wrong code, it is inclusionary (must be accompanied by
another code): coder used only one code and it must be
coupled with a second code (need to choose an additional
correct code & resubmit claim).
- other information:
- social security number on claim does not match insurance
company's listing of the numbers for owner, spouse, and/or
- name of patient (owner, spouse, dependent) submitted
on claim does not match company's exact name listing of
owner, spouse, and/or dependents.
- address information incorrect.
- service payment was denied because of inaccurate claims
formatting (there still is a lack of a uniform claims form for
some of the thousands of payers).
- service payment was denied because THEY say it was ineligible
for coverage (most insurance plans make coverage allowances
for "medically necessary" services):
- because coverage for service should be by the other coverage
program ("co-ordination of [insurance] benefits" disputes):
- your spouse's employer is primary and you are on Medicaid
- Medicare is primary and you have a "medigap" policy
- because service was a duplicate of one already provided
- though the surgery was performed in a "provider" hospital,
the doctor (the pathologist, for example) service was not by
a contracted provider (this is a weak argument; find out if the
hospital has an exclusive contract with that doctor...if so,
an appeal will almost certainly be in your favor because it is
impossible for another doctor to perform the services).
- though part of the doctor's service was approved, they disapproved
other parts (for example, the second of pathology codes 88302 & 88342
was denied as either non-covered or not necessary).
- test was referred to a lab that's not a contracted/network/recognized
provider. [example, HPV test].
- because service was generally "not medically necessary" [about & fighting
- because service was for a pre-existing condition.
- because service was not medically necessary according
to the diagnosis [fighting
- because service was a non-covered benefit (these expenses
are usually not applied to your deductible!) [about & fighting
- periodic "well" or "yearly" check-up: I
am told that some coverages pay if it is "yearly [with
no problems]" and some pay if it is "yearly with/if
there is a problem"...the office simply needs to file
the report in accord with the insurer.
- though a doctor's office staff
and you may have thought this was a "well
check up" when the appointment was set,
your doctor knew (or was prompted by the chart
notes when seeing you) that some action was going
to be taken relative to a situation...therefore,
you were set up with the wrong CPT code & the
wrong visit CPT code was submitted.
- because service occurred after termination of insurance coverage:
- the patient knew (or should have known) that coverage
had expired at the time of the "date of service" by
- services were performed on a specimen or imaging or other
study data performed during coverage but the "add
on" activity was after coverage expired.
- because service has been obtained too often (as when
a provider covers a Pap smear once every 3 years).
- you are a victim of:
service payment was denied because third party authorization
or precertification was not obtained by your treating doctor.
service payment is a low percentage of the bill because insurer
says fee is unreasonable (below the "usual and
customary" fee for that code: call the provider's billing
office and request a current "fee guide" quote for
CPT codes in question, for your provider's geographic area).
The Patient Advocate
- formatting: after provider computers are programmed/set for the typical number of digits of the policy owner subscriber identification number, the huge insurance company adds, say, four more required digits in each subscriber's number...your treating doctor prints a requisition to go with specimen to lab or pathology and the incomplete number is passed on to the lab/pathology billing company and insuror rejects the claim.
- unfortunate timing: in the desire to have everything ready ahead of time for your visit, your doctor's staff has a routine of printing out a patient's requisition sheet with the office's stored insurance info for you. When you come in and re-register with a changed insurance policy, the new info may not get with your specimen to the lab or pathology.
[back to main insurance & billing page]
(posted Sept. 2001; lastest addition 14 June 2006)
1999 - 2006, all rights reserved, Pathology Associates Of Lexington,