American Osteopathic Association

Advancing the distinctive philosophy and practice of osteopathic medicine

How to Handle Claim Denials Effectively

Practices that perform well generally have denial rates below 5%. In addition, most payers expect only a fraction of medical practices will follow up on claim denials and resubmit a corrected version. Clearly, denying your claims saves payers money.

Identifying the primary denial reason is essential. The most frequent reasons for denial are:

  • Registration issues—These include insurance verification, patient information and payer information.

  • Charge entry validation—examples are invalid procedure or diagnosis codes.​​

An extended list of denial reasons includes:

  • Referral and pre-authorization Issues

  • Invalid patient information

  • Duplicate information​

  • Failure to meet medical necessity requirements

  • Missing documentation

  • Bundled or non-covered issues

  • Failure to meet credentialing requirements

  • Failure to file in a timely manner

Remediation of denials

Claims denied for timely filing and never submitted in the permissible timeframe are more difficult to appeal. An appeal may be possible based on a valid reason for not submitting the claim.

Filing claims as quickly as possible is best practice. When you have good systems in place, you will be able to appeal medical billing claim denials effectively and will eventually get paid in most cases.

Source: M-Scribe Technologies​​


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