The claim lacks medical necessity.
The time period for filing the claim had expired.
The claim was submitted to the wrong insurance company.
Incorrect ICD-10-CM, CPT, and/or HCPCS codes were entered.
More than one CPT/HCPCS code was filed for same date of service, and they are mutually exclusive when billed together.
Rationale
Some of the reasons claims are rejected include the claim lacks medical necessity, the time
period for filing the claim had expired, the claim was submitted to the wrong insurance company, incorrect ICD-10-CM, CPT, and/or HCPCS codes were entered, or more than one CPT/HCPCS code was filed for same date of service, and they are mutually exclusive when billed together. The claim being previously paid is not among the most frequent reasons that medical claims are rejected by insurance companies; not a large number of claims that were preciously paid are resubmitted.
Text reference: p. 390
Name
Birth date
Relationship to insured
Whether patient's condition is related to job, automobile accident, or other accident
Rationale
Blocks 2, 3, 5, 6, and 10 a-c of the CMS-1500 Health Insurance Claim Form require the following information for the patient: name, birth date, relationship to the insured, and whether patient's condition is related to job, automobile accident, or other accident. Whether the insured has another health
benefit plan is not covered in Blocks 2, 3, 5, 6 and 10 a-c of the CMS-1500 Health Insurance Claim Form because specifically covers patient information.
Text reference: p. 382
place of service
—Rationale—
A rejection can happen if there is missing information or errors made on a claim. If the patient's name, date of birth, place of service, provider's NPI, CPT code, ICD-10 code, or date of service are missing, the claim will be rejected before it is even considered for payment. An amount due will not cause a claim to be rejected, as the insurance carrier will decide the amount due. Not every service requires an outside lab or an inpatient stay, so they will not cause a rejection if they are missing. Just because a claim does not get rejected, does not mean that it will be paid or denied.
-date of service
-physician's billing address,
-patient's date of birth
—Rationale—-
There are many elements that must be included on a CMS-1500 form. Some of these elements are patient demographics [such as the patient's name, date of birth, and address], physician demographics [such as the physician's name, NPI number, service location, and billing address], and the specifics of the service [such as the date of service, the CPT® codes, and ICD-10 codes]. The chief complaint [written out in word form] and the payer ID are not needed on the CMS-1500 form.
[1] Patient Identification
First step when HP processes claim is to check to see if pt is covered by reviewing:
-Pt name and DOB
-Insured's name
-Insured's ID number
-Date of service [must be within coverage dates]
Example of Rejection:
MCR will reject claim if name and health insurance number do not match name and number contained in MCR Common Working File [CWF].
[2] Rejection Criteria
Requirements
-Is service covered by policy?
-Is service
medically necessary based on submitted diagnosis?
-Were authorization requirements followed?
[3] Rules
A claim is denied if it passes the rejection criteria above but does not meet all HP rules. This denial results in partial payment, delayed payment, underpayment, or no payment. There are three kinds of denials [listed below].
A. Technical Denial: missing or complete claim info
-Demographic errors, incomplete/incorrect insurance info, lack of required pre-certification and
preauth, no continued stay auth, exceeded frequency limitations [e.g. more than 1 mammogram per 12 months]
-Could be for portion of care or entire stay.
B. Clinical Denial: associated with care or service provided and may include the following:
-diagnosis not corresponding to procedure
-service not medically necessary [e.g. MCR requires completion of ABN for non-medically necessary care
-carve-out days [clinical documentation to support care is missing]
-inappropriate level
of care
-HCPCS code is incorrect for procedure performed
C. Underpayment Denial: HP does not pay agreed upon contract amount.
-Challenge: this kind of denial is not always recognized during payment processing, especially if contractual adjustments are not posted at the time of billing
-Example: HP pays claim based only on a fee schedule amount when the provider's contract includes a percentage of charge rate for the particular rev code billed.