• Practice Solutions

3 Standard Denial Reasons and How to Solve Them


Main Points

  • Timely filing denials occur when the claim is not filed according to the timely filing requirements of the insurance company

  • Non-covered service denials occur when a provider does not get authorization for a service or a service is flat-out not covered

  • Out-of-network provider denials occur when a provider is not credentialed with a specific insurance plan

If you have been in private practice for any amount of time and have dealt with insurance then you know what it is like to get a denied claim. That sinking feeling that tells you you aren't going to get paid is gut wrenching.

But there are some very actionable strategies that you can take to avoid those denials and appeal the denials when they come. we're going to explore the three most common denials and what to do when they occur.

Timely filing denials occur when a claim wasn't submitted within the timely filing requirements of the patient's plan. This usually happens because a provider's notes are not done on time or because of a corrected claim that was not filed quickly enough.

The best way to solve this problem is to file an appeal with the insurance company. You will want to include when you submitted a claim, your NPI, and an explanation of why the claim was filed the way it was.

Non-covered service denials occur when a CPT code was billed that is not covered by the patient's insurance plan. Frequent non-covered services include family therapy, psychological testing, or services with specific diagnosis.

The best way to eliminate this denial reason is to complete an eligibility check at the beginning of services. however, if you do receive this denial the best way to fix it is to appeal the insurance company or to have the patient call and challenge insurance company.

According to a recent study, approximately 1% of patients ever challenge their claim denials. Of those 1% that challenge their claim denials 70% saw an overturned denial.

Out-of-network denials occur when a clinician is not listed as an in-network provider for an insurance company. This means that either the provider truly is not credentialed with the insurance company or insurance company has processed the claim incorrectly.

The best way to solve this kind of claim denial is to call the insurance company and to clarify the in-network status of the provider. It will be important to be very clear on how you are credentialed with each insurance company. once you have a clear picture of your credentialing status then you can easily challenge these denials.

No matter what the denial reason you always have the option to appeal. Best practices include keeping accurate documentation around claim submission and denial follow-up.

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