Denial Analyzer
- Incorect Group / Policy Number
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What it Means
Your insurer is unable to locate the group or policy number, or there is a mismatch between one of these numbers and the other information submitted.
What You Can Do
Hospitals and medical billing offices make mistakes, and an incorrect keystroke in a split-second can cause this denial. Contact the provider's office and be sure they have the accurate information in your account -- ask them to repeat it to you number-of-number. You may also benefit from faxing them a copy of your insurance card so they can validate for themselves.
- Pre-Existing Condition
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What it Means
The service is considered by your insurer to be for a medical condition that existed prior to your coverage by them. It is likely that your policy states that it does not cover pre-existing conditions -- most do.
What You Can Do
If the service performed was for a pre-existing condition, consider approaching your provider to explain the circumstance and inquire about a discount or payment plan. If you believe the denial is in error, contact your insurer. You may need to file a formal appeal. An insurer sometimes links a new medical condition to a previous one in error, suggesting that one caused the other. In that case, you may be able to make the claim that this new condition is not related to the others.
- Service/Procedure Not Covered
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What it Means
The service that your provider billed to the insurance is not one that your insurance considers part of your plan
What You Can Do
Contact your insurer to clarify why the procedure or service was not covered. If there is a question as to the accuracy of the denial, contact your provider’s office to ensure the claim was coded correctly.
- Timely Filing
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What it Means
A claim or follow-up documentation was not provided to the insurer timely
What You Can Do
Contact your provider’s office. If they didn’t submit the claim timely, they may need to cover this claim. If they did, they can contact the insurer to provide proof of timely filing.
- Claim Requires Prior Authorization
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What it Means
A valid authorization or precertification is not on file for the service you received
What You Can Do
If a precertification was obtained, locate the authorization or precert number and provide that to your insurer. If this was an emergent or urgent care in which it was not feasible to obtain prior authorization, begin an appeal with your insurer.
- No Authorization/No Precert
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What it Means
A valid authorization or precertification is not on file for the service you received
What You Can Do
If a precertification was obtained, locate the authorization or precert number and provide that to your insurer. If this was an emergent or urgent care in which it was not feasible to obtain prior authorization, begin an appeal with your insurer.
- Patient Not Eligible/Covered at time of service
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What it Means
Your insurer’s records indicate that you were not covered by them at the time of service
What You Can Do
If you were not covered at the time of service, you are responsible for the claim. If you were covered, obtain proof of coverage (such as an insurance card) and provide it to your insurer. Note: In cases of COBRA lapses, you may be able to retroactively reinstate coverage.
- Additional Information/Documentation Requested
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What it Means
Your insurer may request additional documentation such as a medical record, medical history form, or other information.
What You Can Do
Note that these requests usually have a timeline, so treat them with urgency. If you can fill the request, do so. You may need assistance from your provider’s office, such as in the case of a medical record. If so, contact them and they can assist you.
- Claim was billed with incorrect code/XXX code is invalid for this type of service
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What it Means
The claim was billed using medical codes that do not match the service description or what was authorized.
What You Can Do
Contact your provider’s billing office immediately, and put them in touch with your insurer. This is an internal clerical coding issue on the claim.
- Claim requires valid diagnosis code
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What it Means
The claim was billed using medical codes that do not match the service description or what was authorized.
What You Can Do
Contact your provider’s billing office immediately, and put them in touch with your insurer. This is an internal clerical coding issue on the claim.
- Convenience items not covered under this plan
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What it Means
You may have chosen to "upgrade" your service, such as having sedation when it was optional or having a private hospital room, which was not covered under your
What You Can Do
This balance is likely your responsibility unless you find plan documentation indicating it could be covered.
- Plan is not primary payer for charges or claim/Secondary payer issue
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What it Means
According to your insurance, you have multiple plans or methods of coverage, and they are not liable for this particular claim – another plan is
What You Can Do
You likely need to supply information to the medical office on your other insurance policies, or instruct them to bill a different insurer as the primary payer
- Submit claim to your automobile insurance
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What it Means
Your insurer believes that this claim is the result of an accident, so a different insurance should be responsible for the claim
What You Can Do
If you agree that this is an accident-related claim, contact your medical office and request that they bill your auto insurance instead. If this is not related to an accident, contact your insurance to clarify the nature of the injury.
- Injury is the result of an automobile accident
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What it Means
Your insurer believes that this claim is the result of an accident, so a different insurance should be responsible for the claim
What You Can Do
If you agree that this is an accident-related claim, contact your medical office and request that they bill your auto insurance instead. If this is not related to an accident, contact your insurance to clarify the nature of the injury./p>
- Injury is related to work
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What it Means
Your insurer believes that this claim is the result of a work accident, so workers comp insurance should be responsible for the claim
What You Can Do
If you agree that this is an accident-related claim, contact your medical office and request that they bill the workers comp insurance instead. If this is not related to an accident, contact your insurance to clarify the nature of the injury./p>
- Not medically necessary / appropriate
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What it Means
The services rendered are not seen as medically necessary after review by your insurer
What You Can Do
While some services are clearly not medically necessary (e.g. tummy tuck for appearance purposes), others fall in a gray area and may be justified. If you think the denial is not warranted, work with your medical office to begin an appeal to your insurer./p>
- Non-participating provider
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What it Means
The care you received was performed by a non-participating provider or at an out-of-network location
What You Can Do
You are likely responsible for the balance if you didn’t stay within your network for care. If you believe your insurance denied the claim incorrectly, contact the member services number on your card. If the care you received was emergent, begin an appeal with the assistance of your provider’s office. Emergency care is usually exempt of out-of-network denials.
- Out-of-Network
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What it Means
The care you received was performed by a non-participating provider or at an out-of-network location
What You Can Do
You are likely responsible for the balance if you didn’t stay within your network for care. If you believe your insurance denied the claim incorrectly, contact the member services number on your card. If the care you received was emergent, begin an appeal with the assistance of your provider’s office. Emergency care is usually exempt of out-of-network denials.