Claim Denial Fixer

Fix this claim

1. Find proof the claim was sent on time: the clearinghouse acceptance report or the payer’s acknowledgment with its date.
2. If you have that proof, send a reconsideration or appeal with it attached; payers usually reverse the denial when the original submission was within the limit.
3. If the delay came from another payer (for example, waiting on a primary payer’s decision), send that payer’s remittance showing the date it was decided.
4. If there is no proof and no valid reason, the charge usually has to be written off; the patient generally cannot be billed for your late filing.

Stop the next one

• Keep a list of every payer’s filing limit and track each open claim against it.
• Work clearinghouse rejections every day; a rejected claim is not a filed claim.
• Make unsigned notes and unbilled visits visible daily, so no visit waits weeks for a charge.
• Confirm the primary payer at check-in so the first claim goes to the right place.

Fix this claim

1. Check the status of the original claim first; it may already be paid or in process.
2. If the original was paid correctly, the duplicate denial needs no action.
3. If you needed to change the original, send a corrected (replacement) claim that references the original claim number, not a new claim.
4. If two distinct services were really performed, resend with the documentation and the detail that shows they were separate.

Stop the next one

• Check claim status before any resubmission.
• Use the corrected-claim process for changes, never a fresh claim.
• Bill each visit from one system only.

Fix this claim

1. Check whether an authorization exists and was simply missing from the claim; if so, send a corrected claim with it.
2. If none was obtained, ask the payer whether it accepts retroactive authorization for this service; some do within a short window.
3. Otherwise appeal with the clinical documentation showing the service was necessary and urgent if it was.
4. Record the outcome so the same service is flagged next time.

Stop the next one

• Check authorization requirements when the service is ordered, by payer and plan.
• Track every approval with its number, dates and remaining visits, and warn before scheduling outside them.
• Carry the authorization onto the claim automatically.

Fix this claim

1. Run a new eligibility check for the date of service to see the coverage the payer has on file.
2. If demographics were wrong, correct them and resubmit.
3. If the patient has a different plan, bill that plan, watching its filing limit.
4. If there was no coverage, follow your self-pay policy with the patient.

Stop the next one

• Verify eligibility before every visit, not only at registration.
• Ask about insurance changes at every check-in and scan the current card.
• Copy demographics exactly as the payer has them.

Fix this claim

1. Read the payer’s coverage policy for the service and compare it with the note.
2. If the documentation supports the service, appeal with the relevant note, results and the policy criteria it meets.
3. If the diagnosis was coded incompletely, correct it if the record supports a more specific code, and resubmit.
4. For Medicare, if a valid ABN was signed, the patient can be billed; without one, usually not.

Stop the next one

• Document the reason for each service in the note, not only the diagnosis.
• Check the payer’s coverage policy for frequently denied services.
• Give Medicare patients an Advance Beneficiary Notice before services Medicare may not cover.

Fix this claim

1. Read the exact field named in the rejection or denial reason.
2. Correct the field from the source record (the insurance card, the provider’s enrollment details).
3. If it was rejected (never accepted), simply resubmit; if it was denied after processing, send a corrected claim.

Stop the next one

• Capture demographics from the insurance card at registration and verify them with eligibility.
• Keep provider enrollment details in one place and pull them onto claims automatically.
• Check every claim for required fields before it is sent.

Fix this claim

1. Confirm which plan is primary for the date of service.
2. Bill the primary first; then send the secondary claim with the primary’s remittance.
3. If the payer needs updated coverage information, ask the patient to contact the plan, then resubmit.

Stop the next one

• Ask about all coverage at check-in, including spouse or parent plans and Medicare.
• For Medicare patients, use the Medicare Secondary Payer questionnaire at intake.
• Record the order of benefits on the patient record so every claim follows it.

Fix this claim

1. Check whether the services are truly bundled under the payer’s or national correct coding edits.
2. If they were separate (a different site, session or problem), document that and resubmit with the appropriate modifier.
3. If they were not separate, accept the bundled payment; appealing will not change the edit.

Stop the next one

• Check correct coding edits before the claim is sent.
• Use modifiers only when the note shows the services were distinct.

Fix this claim

1. Confirm the exclusion in the benefits returned by the eligibility check or the plan documents.
2. If the service is covered under another plan, bill that plan.
3. If it is truly excluded, bill the patient according to your agreement with them and the payer contract.

Stop the next one

• Check benefits for services that plans often exclude, before the visit.
• Tell patients in writing when a service may not be covered and get their agreement to pay (for Medicare, use the ABN where it applies).

Fix this claim

1. Check the code against the ICD-10-CM version in effect on the date of service.
2. Replace it with the complete, specific code the documentation supports.
3. Make sure each service line points to the diagnosis that justifies it, then resubmit.

Stop the next one

• Update your code set every October and review your most used codes for changes.
• Code to the highest specificity the note supports.
• Check diagnosis pointers on every service line.