Several of you receive denied claims and just don’t have the time to follow up on it. Here are the top 5 reasons we have found claims to be denied.
- Incorrect Location and/or Modifier for the Location. With telehealth still so widely used, we commonly forget to use the correct location and/or the correct modifier. Also make sure you are looking at each of your Insurance Company’s requirements for locations/modifiers as they all differ.
- You are submitting to the incorrect payor. This idea becomes especially confusing with BCBS. For BCBS you must bill to your home plan even though the contract might have a different home state than the one you are in. For others, you might need to submit to a 3rd party you wouldn’t usually submit to. I always verify with the insurance plans where the claim should go if they have a card that I am not used to seeing.
- Denied due to non-covered diagnosis. Some plans have diagnosis exclusions built into the plan. Before submitting a claim, look in your payor space, or contact the insurance company to verify that the diagnosis is allowed on the client’s policy.
- Denied due to non-covered CPT Code. Some plans have CPT code exclusions built into the plan. Several local plans do not cover family/couples counseling and others might not cover group counseling. It is always important to look in your payor space, or call the insurance provider, to see if there are service exclusions on their policy. Something else to note is that several EAP plans do not bill your typical 90837/90834 so you will need to check with them on which CPT code to use.
- Missing/Incorrect Authorization. When working with insurance plans that require pre-authorization, you will want to make sure you have the correct authorization code entered into Box 23 on the CMS-1500 form. If it is missing, or outside of the allowable dates of service, it will deny every single time.
If you find that you don’t have the time to figure out why your claims are being denied and want some help with just the denied claims, reach out to us today to see how we can help. We work with several companies to just help get their denied claims adjusted so they don’t have to spend hours on the phone with insurance companies.