Key takeaways
- A small set of causes drives most denials, and most start before the claim is sent.
- Correct and resubmit simple errors, and appeal when the payer's decision is wrong.
- Review denials by reason each month and fix the upstream step.
Every practice gets denials. The difference between a practice that gets paid and one that falls behind is whether denials are worked, and whether the cause is fixed so the same denial does not return next month. Here are ten common reasons, in plain terms, with the fix for each.
1. Patient not eligible on the date of service
Coverage ended, changed, or was never active. Fix: verify eligibility before every visit, not just the first one, and update the plan on file when the patient tells you about a change.
2. Missing or invalid prior authorization
The payer required approval and none was on file, or the visit fell outside the approved dates or units. Fix: check authorization rules by payer and service, and track authorized visits so the team knows when to request more.
3. Missing or incorrect patient or insurance details
A wrong date of birth, a misspelled name, or an old member ID. Fix: scan the card at each visit and confirm demographics at check in.
4. Duplicate claim
The payer thinks it already received this service. Often a claim was resubmitted while the first one was still processing. Fix: check claim status before resubmitting, and use a corrected claim rather than a new one when you change something.
5. Timely filing limit missed
The claim reached the payer after its deadline. Medicare generally allows 12 months from the date of service, while many commercial and Medicaid plans allow far less. Fix: submit daily, watch rejections at the clearinghouse, and keep proof of timely submission.
6. Coding errors
An invalid code, a diagnosis that does not support the procedure, or a code that does not match the documentation. Fix: scrub claims before submission and audit a sample of charts regularly.
7. Missing or wrong modifier
Many denials come from modifiers, for example two procedures that bundle unless a modifier shows they were separate. Fix: apply NCCI edits and payer rules in your claim scrubber, and make sure documentation supports the modifier.
8. Medical necessity not supported
The payer does not see why the service was needed. Fix: link the right diagnosis, follow payer coverage policies, and make sure notes describe the need clearly.
9. Coordination of benefits
The payer believes another plan should pay first. Fix: ask about other coverage at check in, update primary and secondary order, and send the primary EOB with secondary claims.
10. Provider not enrolled or credentialed
The rendering provider is not active with that payer, or the enrollment lapsed. Fix: track credentialing status by provider and payer, and check it before scheduling.
Fix the cause, not just the claim
Working a denial means correcting and resubmitting or appealing the claim. Managing denials means grouping them by reason, payer, and provider each month to find the pattern behind them. If eligibility denials keep appearing, the fix is at the front desk. If one code keeps denying, the fix is in coding or documentation.
Track denials by reason code every month. A short report showing the top reasons and what changed is often the most useful report a practice owner reads.
Where Afiable helps
Afiable reviews denials by code, payer, and specialty, fixes the cause, appeals where appropriate, and reports the trends so repeats go down. Book a free audit and we will review a sample of your denials and show you what to fix first.
Questions practices ask
What is the difference between a rejection and a denial?
A rejection is returned before the payer accepts the claim, often at the clearinghouse, so it must be fixed and resent. A denial is a decision made after the payer processed the claim.
How quickly should denials be worked?
As soon as possible. Appeal and corrected claim deadlines start running from the denial, and older denials are harder to resolve.
This article is general information for practice owners and managers. Payer policies and regulations change, so confirm current rules with each payer before acting.