Top 7 Claim Denials


The best way to keep your income stream flowing properly is to prevent claim denials.  Read below for the top 7 denial reason codes and prepare a strategy to keep them to a minimum in your practice.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, many of these types of denials will become a thing of the past.

1.      18 – Duplicate claim/service.
Manual keying of services lends itself to duplicate entry of those services.   A configurable Claim Scrubber as found in Iridium Suitewill check each service entered and alert the user immediately if the same service is already on record.
2.      16 – Claim/service lacks information which is needed for adjudication.
Some payers have specific claim rules that require “non-standard” 5010 format information be included on their claims.  An example is the rendering provider’s Taxonomy code in addition to the standard NPI.  Iridium Suite allows the user to include this specialized data on the claims to those individual payers as needed.  
3.      97 – Payment is included in the allowance for another service/procedure.
Government payers, such as Medicare, as well as the larger Commercial payers have adopted the NCCI standard for “bundled” services.  The Iridium Suite Claim Scrubber comes standard with all current NCCI edits built in.  The Scrubber alerts the user when entering two or more procedures that are considered inclusive of each other.
4.      29 – The time limit for filing has expired.
Payers each have their own time filing limits guidelines for claim submission.  It can be as short as 60 days, or the current Medicare limit is 12 months.  The sooner you submit your claims, the quicker you will receive your payment and eliminate the risk of untimely filing denials.  With the Connectivity Clearinghouse within Iridium Suite, you can import patient demographic and service data directly into the billing software from your EHR/EMR.  Your patient and charge entry process can be almost completely automated allowing for close to “real time” claims submission for your services.
5.      50 – These are non-covered services because this is not deemed a ‘medical necessity’ by the payer. 
The key to preventing these types of denials is being aware of your payers Medical Policies. These two Biller’s Blogs provide insight on both Commercial Payers and Medicare:
6.      140 – Patient/Insured health identification number and name do not match.
By utilizing the Real Time Eligibilityfunction in Iridium Suite, you can virtually eliminate denials like the one above or similarly “subscriber not eligible at time of service.”  You will be able to successfully submit charges to the correct active payer with the proper identification number and receive your proper claims reimbursement on the first submission.
7.      197 – Payment adjusted for absence of precertification/authorization.
A medical billing software with the ability to indicate payers requiring authorization as well as track a multiple service/visit authorization as it is assigned to the performed procedures is crucial in assisting office staff with this issue.  Iridium Suite provides a specific area in the patient insurance information section to indicate authorization requirements and to record the authorization details.  Before a claim can be submitted, it is scrubbed for authorization requirements and will warn the user if the authorization is missing.  You are unable to submit the claim without the appropriate authorization.
By being aware of the common denials your practice receives, you can develop the necessary processes to prevent them before they happen.  Having the best medical practice billing software, Iridium Suite, can give you a head start with its many advanced functions.