Top Three Claim Denials - And How To Avoid Them

Date: 09/26/17

The top three most common claim denial reasons are Service Not Covered, Duplicate Claim, and Authorization Not On File. Here are some tips to help you avoid these claim denials:

Denial Reason: Service Not Covered (EX46)

How to avoid it: Always check the Medicaid Fee Schedule on the LDH websiteExternal Link or the Specialized Behavioral Health Fee ScheduleExternal Link first to determine if the CPT/HCPCS code is covered. If the service is covered on the appropriate fee schedule for your specialty, check to make sure that it’s covered in your individual contract. Don’t forget to also make sure that the rendering provider is qualified to provide the services billed!

Denial Reason: Duplicate Claim (EX18)

How to avoid it: The duplicate claim denial often occurs when a practice is attempting to bill a correction to a previously submitted claim. To help prevent this, be sure to include the appropriate frequency code or resubmission code in field 4 of the UB-04 and in field 22 of the 1500, and make sure to include the original claim number in field 64 of the UB-04 and in field 22 of the 1500. This requirement is part of the National Uniform Claim Committee (NUCC) guidelines. Please remember that the corrected claim will replace the original claim. To that end, remember to also include all service lines that paid correctly on your corrected claim to avoid recoupment of those services lines. (To request reconsideration of a claim, use this helpful form.)

Denial Reason: Authorization Not On File (EXA1)

How to avoid it: Always make certain that the rendering provider or practitioner is in-network. Then use the Pre-Auth Needed? tool on our website to find out if the service requires an authorization. Once you request and get the authorization approved, verify that the claim matches the services, dates and other approved details of the authorization – these details must match the information on the claim.

Have questions about your claims? Contact your dedicated Provider Consultant, or call Provider Services at 1-866-595-8133, Monday – Friday, 7 a.m. – 7 p.m. You can also review your claims in our secure provider portalExternal Link at your convenience – and don’t forget that our Provider Manual is also a great resource for claims information!