Most Common Reasons for Medical Billing Claim Denial
                     Most Common Reasons for 
Medical Billing Claim Denial
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 Medical billing claim denials 
affect physician practice and 
cash flow. 
 By reducing the claim denials 
rate, you can enhance your 
Introduction practice profitability and 
reduce administrative costs.
  
 To overcome the issue with a 
claim denial, it is important to 
understand the common 
reasons for claim denial. 
 Let us discuss the most 
common reasons for 
medical billing claim denials.
Incorrect Patient 
Identifier Information
 Patient identifier information is the most important one 
to submit a medical claim with precise patient 
identifier information that helps the health insurance 
company to find the patient’s health insurance plan to 
make payment.
 Most of the claims denied because of inaccurate 
patient identifier data are:
 Incorrect subscriber or patient name 
 Incorrect subscriber or Patient’s date of birth 
 Incorrect subscriber numbers 
 Incorrect subscriber group number
 Insurance ineligibility
No Referral on File
 Most of the insurance companies adopted the 
referral process. If the patient has not got a 
referral from their primary care physician, then 
the physician should not provide service. 
 In such a case, the claim is submitted prior to 
the primary care physician’s referral, then the 
claim will be denied.
Claim Was Filed After 
Insurer’s Deadline
 If the claim is not filed before the insurer’s deadline, 
then it gets denied. Be aware of timely filing deadlines 
(TFL). Here a few examples of timely filing deadlines. 
 United Health Care
 Timely filing deadlines are mentioned in the 
provider’s agreement.
 Aetna
Physician: The claims must be submitted within 90 
days from the date of service.
Hospitals: The claims must be submitted within one 
year from the date of service.
 Tricare
Claims must be submitted within one year from the 
date of service.
Missing or Invalid CPT
 or HCPCS Codes
 For the medical claim process, the healthcare industry 
uses standard codes to point out services and 
procedures. 
 This coding is called Current Procedural Terminology 
(CPT) or Healthcare Common Procedure Coding 
System (HCPCS). These codes change frequently. 
 So it is important to ensure whether your medical coder 
stays up to date with revised codes.
Lack of Documentation 
to Support Necessity    
If the payer is not confident of the medical necessity of 
the procedure, the claim will be denied. In such a case, 
they may require an additional document to adjudicate 
the claim. For that, medical records include the following 
items:
 Patient medical history
 Patient physical reports
 Physician consultation reports
 Patient discharge summaries
 Radiology reports
 Operative reports
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