It’s important to understand the reasons why medical claims get denied by insurance companies so you can prevent them in the future.
Incorrect Patient Information
Some of the most common mistakes that can cause a claim to deny due to incorrect patient identifier information are:
- The subscriber or patient’s name is spelled incorrectly
- The subscriber or patient’s date of birth on the claim doesn’t match the date of birth in the health insurance plan’s system
- The subscriber number is missing from the claim or invalid
- The subscriber group number is missing or invalid
Prior Authorization or Precertification Required
Many services considered as non-emergency-related may require prior authorization. It is customary for most insurance payers to require prior authorization for expensive radiology services such as ultrasound, CT, and MRI. Certain surgical procedures and inpatient admissions may also require prior authorization. Services will not be denied if the services rendered are considered as a medical emergency.
Coverage Is Terminated
Verifying insurance benefits prior to services being rendered can alert the medical office if the patient’s insurance coverage is active or has terminated. This will allow you to get more up-to-date insurance information or identify the patient as a self-pay.
Be aware of timely filing deadlines for each insurance carrier. Some examples of timely filing deadlines include:
- United Health Care: Timely filing limits are specified in the provider agreement
- Cigna: Unless state law or other exception applies –
- Aetna: Unless state law or other exception applies –
- TRICARE: Claims should be submitted within one year after the date of service.
Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance.
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