By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: 10 Reasons Your Claim Was Denied
Share
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Business > Finance > 10 Reasons Your Claim Was Denied
BusinessFinanceHospital Administration

10 Reasons Your Claim Was Denied

Abby Norman
Abby Norman
Share
6 Min Read
claim denials
SHARE
claim denials 

There are many reasons a claim might be denied, but did you know that many of them are actually simple oversights that can easily be corrected?

Contents
  • 1. Missing or Incorrect CPT or HCPCS Codes
  • 2. The patient didn’t have a referral, or, if they did, it wasn’t documented anywhere.
  • 3. The claim is part of a worker’s compensation claim.
  • 4. The claim wasn’t filed soon enough.
  • 5. The insurance company requested medical records, and didn’t get them.
  • 6. The services just aren’t covered.
  • 7. The insurance receiving the bill isn’t the patient’s primary insurance.
  • 8. The services were not pre-certified.
  • 9. The patient’s key identifying information is missing.
  • 10. The patient’s coverage has been terminated.
claim denials 

There are many reasons a claim might be denied, but did you know that many of them are actually simple oversights that can easily be corrected? Check your denials against this list to see how many preventable errors might be costing your hospital money.

1. Missing or Incorrect CPT or HCPCS Codes

When medical coders are working in a record, particularly now that everything is electronic, occasionally they may not input a necessary code on the account. Typically, with the electronic coding procedures, there are safety nets in place to prevent a record from going through if anything is missing or doesn’t cross-reference correctly. Of course, it’s still an imperfect technology, so it’s important that coders do their best to double check their work- and not rely entirely on these stopgaps.

2. The patient didn’t have a referral, or, if they did, it wasn’t documented anywhere.

In this case, a single missing piece of documentation can cost a lot of money. Referrals are particularly sensitive to scrutiny, so it’s important that they are documented in a timely manner by the physician- or, if the patient didn’t obtain a referral, this should be documented in the record so it can be billed accordingly. Any gray area within the record will only open it up to review and, of course, possible denial.

More Read

Trends in Medical Care – Overview
What You Need to Know About This Year’s AdvaMed Conference
Pharma: Funding R&D: High Prices, Overuse A Failed Strategy
The Importance of Collaboration in Your Hospital
Virtual Visits: Cutting Healthcare Costs

3. The claim is part of a worker’s compensation claim.

This fact in and of itself doesn’t necessarily open the claim up to denial, but if the claim was coded as such prior to the worker’s compensation insurance’s claim was filed, then there could be trouble. This is usually an issue with timing and coordination of billing.

4. The claim wasn’t filed soon enough.

Sort of dovetailing with the worker’s compensation issue is the issue of “timely filing” – most carriers have required deadlines that must be met in order to be eligible for coverage. If those aren’t met, the claim is very likely to be denied.

5. The insurance company requested medical records, and didn’t get them.

The medical records department of any hospital is almost always far more strapped for time and resources than anyone in the hospital would imagine. That being said, when they are inundated with requests, it’s up to the release of information clerk to make sure that each insurance company gets the requested records in a timely manner. That being said, it’s up to the insurance company to properly request records: most often the delay comes from insufficient or error-filled requests from companies that cannot be processed by the medical records department. So, culpability from both the clerks and the insurance companies is necessary to prevent these delays.

6. The services just aren’t covered.

Sometimes, everything in writing is correct, it was filed in a timely manner, nothing is missing, but quite simply, the services being billed for just aren’t covered by that particular insurance plan. That being said, the insurance company is generally responsible for notifying the patient that services are not covered before they bill them for it.

7. The insurance receiving the bill isn’t the patient’s primary insurance.

Sometimes, the lack of coordination between a patient’s benefits can cause errors and delays in processing. Patients who are covered by multiple insurances (like patients who have Medicare benefits in addition to insurance through a spouse or their employer) may be more likely to bill services to the wrong insurer.

8. The services were not pre-certified.

This is usually pretty cut and dry as far as the insurance carrier is concerned: if the services were rendered without pre-certification, they won’t pay. You can, as always, file an appeal, but in this case, you’re unlikely to win.

9. The patient’s key identifying information is missing.

In some cases, an incorrect medical record number or date of birth can throw off the entire billing procedure. This is why it’s extremely important that coders don’t rely entirely on the electronic medical record, and patient identifiers should always be cross-referenced with what’s listed in the chart so that these errors can be caught and corrected before the claim is sent.

10. The patient’s coverage has been terminated.

Finally, in some instances, the patient’s insurance is terminated during or just before a treatment or service is rendered. They may be unaware of the termination at the time, but when the claim is denied, it may be made known to them. In some cases, it’s a simple fix, but for some they may not be eligible for additional coverage.

Share This Article
Facebook Copy Link Print
Share
By Abby Norman
My name is Abby Norman and I am a healthcare blogger. With over 10 years of experience in the medical field, I have developed a passion for helping others understand the complexities of healthcare.

Stay Connected

1.5kFollowersLike
4.5kFollowersFollow
2.8kFollowersPin
136kSubscribersSubscribe

Latest News

dental care
Importance of Good Dental Care for Health and Confidence
Dental health Specialties
October 2, 2025
AI in Healthcare
AI in Healthcare: Technology is Transforming the Global Landscape
Global Healthcare Policy & Law Technology
October 1, 2025
Choosing the Right Swimwear for Health and Safety
News
September 30, 2025
sports concussions
Concussion In Sports: How Common They Are And What You Need To Know
Infographics
September 28, 2025

You Might also Like

Hip Fractures in Women Deadly

November 28, 2011

Iowa’s in the National News Right Now, and It’s for a Reason You Wouldn’t Expect

June 3, 2015
Image
BusinessNews

Choosing Wisely and Delivering Value in Obstetrics & Gynecology

April 29, 2013
BusinessHospital AdministrationPolicy & Law

Pay-for-Performance Attacks Hospitals – Shake Down or Fair Play

December 5, 2011
Subscribe
Subscribe to our newsletter to get our newest articles instantly!
Follow US
© 2008-2025 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Username or Email Address
Password

Lost your password?