Denial Analyzer

Incorect Group / Policy Number

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.