Making Sense Of Medical Billing Denial Codes

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Medical bills can sometimes seem difficult to decipher, particularly for those who are not in the healthcare industry. One of the most confusing aspect of a medical bill may be any denial codes. It is important to your financial and medical well being that you understand all codes on your bill, not least of which, the medical bill denial codes. Here are a few common denial codes and what exactly they mean.

Coverage Terminated

This is the code that applies when you have received care even though your policy has lapsed. It is important to make sure that you stay current on all premium payments and that you do not allow your policy to expire.

Incorrect Patient Identifier Information

This code may appear on your bill if the information your insurance company receives from your doctor or hospital is incomplete or incorrect. This can include a misspelling of your name, an incorrect date of birth, or an incorrect insurance group number. If you receive a bill with this code, call your health care provider’s office and clear up any information that is missing or incorrect on your bill.

Requires Prior Authorization or Pre-Certification

Different companies and policies have different requirements when it comes to authorization for treatments. Many policies require that you receive authorization before receiving certain services. While emergency services do not require authorization, many expensive procedures like surgery, as well as MRI’s and other expensive procedures do.

If you plan on visiting a doctor or a hospital for an non-emergency procedure and are unsure whether you need authorization, call your insurance company and check.

Services Excluded

Part of the reasons many insurance companies require pre-authorization is that there are some procedures that are not covered by your policy. If you have received a service that is not covered by your policy, your insurance company will deny payment and you will be responsible for all of the charges on your own.

Request For Medical Records

In some cases, your insurance company may mandate that you or or physician submit relevant medical records before the claim is paid. Your insurance company may make their decision about whether your care will be paid for based on things like past physicals or hospital stays.

Coordination of Benefits

If you are covered by more than one policy, as in an instance where you are covered by both your own policy and your spouses, your insurance carrier may deny a bill on the basis that benefits must be coordinated between both companies before the bill can be settled. This may particularly be the case if the company issuing the denial code is not your primary insurance carrier.

Bill Liability Carrier

If your doctor or hospital visit has occurred because of an accident you were in in your automobile or on a job site, your insurance carrier may deny your claim on the basis that your claim should be paid by your car insurance or workmen’s compensation insurance.

If you get a bill with this code and your claim is not being paid by your auto insurance, you should contact your insurance company and explain immediately.

No Referral On File

Depending on the type of policy you have and the type of procedure you are getting, you may need to get a referral from your primary care physician in order to have your procedure covered.

Some plans, such as HMO’s, require that you have one primary care physician who will refer you to a specialist if necessary. Make sure that you obtain all necessary referrals and that you fully understand when a referral from your primary care physician is necessary.

For more information check out our FAQs For Health Insurance & Medical Billing