3 Common Reasons for Claim Denials.
If you want to get our clean claims without delays, continue reading. I have included below the three most common reasons for claim denials. Our time is precious, and we want to be as efficient and productive as we can be. So that means not wasting hours on the line waiting for customers services representatives and then being transferred from one department to the next wasting time. The solution is to submit accurate claims. Below you will find what I consider the top three reasons for claim denials.
3 Common Reasons for Denials
- Incorrect demographic information
Incorrect demographic information. Claims will be denied if the data regarding the member is not consistent with their information. The Devil is in the details. Be sure to have the correct spelling of the member’s name, the correct DOB, address, and member ID numbers
- Incorrect Payor ID
When you are contracted with the insurance panels you will be provided an in-network contract with your local insurance company. If you are using an Electronic Medical Record, the Payor ID is the identifying number for where the claims will be processed. Many claims are denied when the claims arrive to a different location other than your local region in which you are contracted in. For example, if you are contracted with your Local United Behavioral Health in New Jersey and you sent the claim to United Behavioral Health in Virginia, you will be considered out of network and will receive a denial. To avoid this, when verifying the benefits and eligibility prior to seeing a client for the first visit, ask the customer services representative to verify the address where claims should be sent and the Payor ID if sending claims electronically.
- Provider out of network
Another common reason for a claim denial is if the provider who rendered the service is out of network. Because insurance companies may have many products listed under one umbrella company it is important to read your contract carefully to determine which products you are in network in and in your eligibility and verification process ensure that the customer service representative confirms that your specific NPI number is in network with the plan.
I cannot stress enough the importance of investing the time up front to verify a client’s plan benefits before offering an appointment. It will save you so much time.
If you have further questions and would like to learn more about billing, our Billing 101 Online Course is designed to teach you billing fundamentals and help you bill claims accurately for rapid reimbursement.
For immediate access to this training click here.
Your Partner in Success,
Prunella Harris, LCSW
Private Practice Coach