Denial Actions

	A	B	C	D	E
1	Type	Denial Reason	Clarification	Actions	Resources (if applicable)
2	Coding	Non-covered procedure	Procedure not eligible for payment	Call the insurance and ask why and if you can bill the patient. If you are allowed to bill the patient, transfer responsibility to the patient. If the insurance tells you that there was a problem with the claim, address that problem and resubmit for payment	Check Medicare's web site for valuable information about procedure coverage guidelines. This information can be found in the local coverage determinations section. Although you may receive this error from insurances other than Medicare, their guidelines are still a helpful resource.
3	Coding	Missing / invalid CPT	Procedure code is wrong	Check the codes in CPT to make sure that they are valid for the current year. correct the invalid code based on the information found in the CPT look up and resubmit claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
4	Coding	CPT invalid for patient's age	CPT code is age specific and the patient's age is outside of the range	Look up the CPT code and compare the patient's age to this age range listed as applicable. Search for a similar code that is appropriate for the patient’s age. This is a common denial for routine / well visits (codes 99381-99387 and 99391-99397). These codes are listed in age order. change the CPT code and resubmit the claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
5	Coding	CPT invalid for patient's sex	CPT code is sex specific and patient doesn't match sex requirements	Check the patient’s sex in the chart and if it is clearly wrong change it. Make necessary corrections to patient's sex and resubmit the claim. If the patient's sex is correct tell the doctor about the discrepancy and ask for a corrected CPT code. correct CPT code and resubmit the claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
6	Coding	Diagnosis invalid for patients sex	ICD-9 code is sex specific and patient doesn't match sex requirements	Check the patient’s sex in the chart and if it is clearly wrong change it. Make necessary corrections to patient's sex and resubmit the claim. If the patient's sex is correct tell the doctor about the discrepancy and ask for a corrected ICD 9 code. correct diagnosis code and resubmit the claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
7	Coding	Missing / incomplete invalid diagnosis code	The ICD 9 is wrong	Check the diagnosis codes to be sure they are valid for the current year. Make the necessary corrections and resubmit the claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
8	Coding	Missing / invalid incomplete procedure code	The CPT is wrong	Check the procedure codes to be sure they are valid for the current year. Make the necessary corrections and resubmit the claim	Always make sure that you have the current year CPT and ICD-9 book available. Codes change annually.
9	Coding	Missing invalid HCPCS modifier	The modifier is not correct	Review the modifiers on each charge and be sure that they are applicable. Remember that some are applicable to evaluation and management and others work only on procedures. Make the appropriate correction and resubmit the claim	Modifiers can be found in the CPT book.
10	Coding	Add-on code cannot be billed by itself.	Some codes, identified in CPT by a + sign, must be billed in conjunction with another code. These are called add on services and compliment a "main procedure"	Check in CPT to verify the codes. CPT will indicate the main procedure. Verify with your doctor that the "main procedure" wan in fact preformed, if so add it to the claim and resubmit	The complete list of add on codes can be found in CPT
11	Coding	Procedure not payable for diagnosis	The diagnosis code does not justify the procedure billed	Check on Medicare's web site to review the Medicare coverage determinations for applicable diagnosis. Review the list of diagnosis with the doctor and ask them to advise which diagnosis is most correct	Check Medicare's web site for valuable information about procedure coverage guidelines. This information can be found in the local coverage determinations section. Although you may receive this error from insurances other than Medicare, their guidelines are still a helpful resource.
12	Coding	Services have been rebundled	Bundling edit	This may be an indication that you have billed codes that cannot be billed separately (in other words, they are bundled according to CCI). Check CCI first and if appropriate according to the CCI rules and documentation I the patient’s chart, review the claim for appropriate modifier. Append modifier as necessary and resubmit the claim.	CCI edits can be reviewed in a spread sheet format. This will help you to determine if a modifier will be acceptable. Check out the edits on CMS web site at : http://www.cms.hhs.gov/nationalcorrectcodinited/ncciep/list.asp#TopOfPage
13	Coding	According to CCI this service is not separately payable	bundling edit	This may be an indication that you have billed codes that cannot be billed separately (in other words, they are bundled according to CCI). Check CCI first and if appropriate according to the CCI rules and documentation I the patient’s chart, review the claim for appropriate modifier. Append modifier as necessary and resubmit the claim.	CCI edits can be reviewed in a spread sheet format. This will help you to determine if a modifier will be acceptable. Check out the edits on CMS web site at : http://www.cms.hhs.gov/nationalcorrectcodinited/ncciep/list.asp#TopOfPage
14	Demographic	Patient not found in system	Patient's name, id or insurance is invalid.	Review a copy of the insurance card. Be sure that the patient's name and ID is entered exactly as it is on the insurance card. Fix the patient's information and resubmit all claims in this patient's account.	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
15	Demographic	Missing/incomplete patient name	Patient's name is wrong	Review a copy of the insurance card. Be sure that the patient's name is entered exactly as it is on the insurance card. Fix the patient's information and resubmit all claims in this patient's account	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
16	Demographic	Missing/incomplete HICN	Patient's insurance id or name is wrong	Review a copy of the insurance card. Be sure that the patient's name is entered exactly as it is on the insurance card. Fix the patient's information and resubmit all claims in this patient's account	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
17	Demographic	Member not found	Patient's insurance id or name is wrong	Review a copy of the insurance card. Be sure that the patient's name and insurance id is entered exactly as it is on the insurance card. Fix the paitent's information and resubmit all claims in this patient's account	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
18	Demographic	Maybe covered by another primary insurance	Another insurance may be primary	Contact the patient for better insurance information then resubmit the claims with the corrected information
19	Demographic	Patient covered by HMO	Another insurance may be primary	Contact the patient for better insurance information then resubmit the claims with the corrected information
20	Demographic	Missing/incomplete/invalid patient birth date	Patient's birth date is wrong	Contact the patient for better insurance information then resubmit the claims with the corrected information
21	Eligibility	Patient not eligible on date of service	Patient's insurance is expired.	Contact the patient for better insurance information.	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
22	Eligibility	Coverage not in effect on date of service	Patient's insurance is expired.	Contact the patient for better insurance information.	Try checking the patient's eligibility by social security number search or name search on the insurance's web site.
23	Eligibility	Patient not covered on this policy	Patient's insurance is not valid	Contact the patient for better insurance information.
24	Practice	Rendering physician ID or NPI missing / invalid	The Doctor's provider number is wrong or missing	Check in your practice management system to see if it is entered. Call the insurance company prepared with the provider tax id. Explain to them that we may have an invalid provider number, but we have the tax id. Ask them to check the number for us and/or provide the correct number. Remember a provider may have an individual number and a group number, ask about both. It is possible not have a group number but ASK anyway. Get the correct information and enter it in to your practice management system. Once you have corrected the provider numbers resubmit ALL claims out to this insurance. (you should run a complete AR report by insurance and send ALL claims out to this insurance in the entire account)
25	Practice	Missing / incomplete invalid UPIN or NPI for the ordering provider	Referring doctor's ID number is invalid	Check the CPT code. For diagnostic tests, the rendering doctor may refer to themselves. If is it a consult (99241-99245 or 99251-99255) an outside doctor is required. Look through the patient's medical record to determine who requested the consult. Add the referring doctor’s name, UPIN and NPI and resubmit a corrected claim.	Both UPIN and NPI have on-line registries to obtain this information. To check a UPIN go to: www.upinregistry.com or to check an NPI go to: https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
26	Practice	Claim lacks CLIA certification number	CLIA number is missing. this is applicable to cpt codes in the 80,000 series only (lab tests)	Look in your practice management system to see if the CLIA is listed. If it is not add the number. The number can be obtained on your practice's CLIA certificate. Remember that most doctors’ offices perform many CLIA waived tests. Check the CPT code to see if a QW modifier is required. Resubmit the claim with the CLIA number and modifier as necessary.	You can view the complete list of CLIA waived tests to determine if the QW modifiers necessary on the FDA web site at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/testswaived.cfm
27	Submission	Untimely filing	The claim was not filed within the insurance's allowed time frame	Ask the insurance what timely limits are? Review EDI submissions reports within the timely filing date range; look for a clean claim submission. Print the edit report containing a clean claim submission and attach it to a paper claim. Write on the paper claim "Proof of timely filing attached"
28	Submission	Service not authorized	There is no precertification is recorded in the insurance's system	See if there is an applicable note or authorization listed in the patient's chart. If there is an authorization number listed, call the insurance back, provide that authorization number and ask that the claim be reprocessed. If there is no authorization at all, call the insurance and ask if they allow retroactive precertification, if yes, please precertify. If no the claim may need to be written off.
29	Submission	Claim not on file	The insurance can't find the claim	Call and ask the insurance to verify their address and ask for the "Payor ID" number. Ask the insurance representative if you can have a fax number to fax the claim. check your EDI reports to see if the claim rejected electronically. If you find an error, fix it and resubmit the claim. If no error is found check that we are sending to the correct payor ID,	You can obtain most payor id numbers from the insurance's EDI department. You can also see a complete list of payor ID numbers on Emdeon's web site at: http://www.emdeon.com/PayerLists/payerlists.php
30	Coding	Procedure not paid separately	bundling edit	Review the claim for appropriate modifier. Append modifier as necessary and resubmit the claim.	CCI edits can be reviewed in a spread sheet format. This will help you to determine if a modifier will be acceptable. Check out the edits on CMS web site at : http://www.cms.hhs.gov/nationalcorrectcodinited/ncciep/list.asp#TopOfPage
31	Submission	Duplicate	The exact same claim was received more than once	Look in the patient's account to see if the claim has been processed successfully. If it has not, call the insurance to find out what happened to the first claim. Make corrections based on the original denial reason and resubmit the corrected claims
32	Submission	Paid in capitation	Payment method for primary care physicians and some physical therapy services	If your doctor is a primary care physician check that the patient is listed on your monthly capitation roster. If they have been paid under capitation, write off the capitated codes. If the doctor is NOT a primary care physician or the patient is not on the capitation roster, call the insurance to dispute the denial and ask them to reprocess the claim correctly.
33	Submission	Previously paid	Claim was already processed	Call insurance and ask for payment detail including check number, check date, payment amount, patient responsible amount and if the check cleared. Also ask for a duplicate EOB and copy of the cancelled check. Once you have received the cancelled check copy, verify that your practice cashed it and if so post the payment. If the check was not cashed you may have to assume that the payment was lost in the mail and ask the insurance to reissue the check.
34	Submission	Information submitted does not support frequency or level of service	Procedure done too often	Ask the doctor if there was a reason why the procedure was necessary more often. If the doctor has a legitimate reason for the frequency, appeal the claim with medical notes and a cover letter. if the doctor has no reason, please let them know that the claim will not be paid and may need to be written off	Check Medicare's web site for valuable information about procedure coverage guidelines. This information can be found in the local coverage determinations section. Although you may receive this error from insurances other than Medicare, their guidelines are still a helpful resource.
35	Submission	Needs more information	Needs more information	Call the insurance and ask what information do they need and from whom? Also ask where the information needs to be sent (address, fax). If they need information from the patient, contact the patient. if they need information form the doctor, prepare a paper claim, attach the necessary documentation and resend the claim
36	Submission	Service not covered in this place of service	CPT does not correspond with the place in which it was billed	Look up the CPT code to see if the CPT code wording indicates that the procedure is specific to a particular place of service. (For example 99232, specifically says in-patient). Confirm the location where the services were preformed with the doctor first. Make any necessary corrections to the facility attached to the claim.	CMS website has a complete list of place of service codes. You can find the information at: http://www.cms.gov/place-of-service-codes/
37	Submission	Invalid "to" date of service	the ending date of service is wrong	Review the charges and correct the date. The mistake is usually obvious such as the dates may be reversed. Correct the date and resubmit the claim
38	Submission	Invalid "from" date of service	the ending date of service is wrong	Review the charges and correct the date. The mistake is usually obvious such as the dates may be reversed. Correct the date and resubmit the claim
39	Submission	Invalid place of service	CPT does not correspond with the place in which it was billed	Look up the CPT code to see if the wording indicates that the procedure is specific to a particular place of service. Confirm the location where the services were preformed with the doctor first. Make any necessary corrections to the facility attached to the claim.	CMS website has a complete list of place of service codes. You can find the information at: http://www.cms.gov/place-of-service-codes/
40	Submission	Missing incomplete national drug code	This is a drug reference code required by some insurances for claim submission	Check first with the insurance to see if they also require dose and administration route information in addition to the drug code. Add the NDC code to the claim. Your practice management system usually will have a specific location for that information.	The FDA maintains the NCD (national drug code) list. You can view the list and search for drug numbers on the FDA web site located at: http://www.fda.gov/cder/ndc/
41	Submission	Missing/incomplete/invalid admission date.	Services rendered in the hospital will require the date of hospital admission	Check the patient's chart to locate the admission date on the hospital forms, add this date to your claim and resubmit
42	Submission	Invalid missing provider number or NPI	The Doctor's provider number is wrong or missing	Check in your practice management system to see if it is entered. Call the insurance company prepared with the provider tax id. Explain to them that we may have an invalid provider number, but we have the tax id. Ask them to check the number for you and/or provide the correct number. Remember a provider may have an individual number and a group number, ask about both. It is possible not have a group number but ASK anyway. Get the correct information and enter it in to your practice management system. Once you have corrected the provider numbers resubmit ALL claims out to this insurance. (you should run a complete AR report by insurance and send ALL claims out to this insurance in the entire account)