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Why is Your Claim Not Processing?

The majority of insurance carriers are mandated to deny or pay a claim within 30 days of receiving it. As a practice, you know you need to receive payment from the carrier (and the patient, for that matter) as quickly as possible. You also know this doesn't always happen. Why? 

A Proactive Approach

A few proactive approach steps on handling claims denials include:

  • Expect payment in 15 days of a claim approval by the carrier.
  • Make sure you analyze the reasons for any claims denials.
  • Follow up with the carrier on a timely basis to obtain claim payment status.
  • If payments are averaging more than 30 days, develop a comprehensive process for claim follow up to improve your cash flow and accounts receivable results.
  • Consider following up in as soon as 7 to 10 days after submitting your claim to the carrier.

Common Claim Denials

Claim not on file | Authorization or precertification | Claim pending for additional information from the member/provider | Coverage terminated | Request for medical records | Incorrect patient identifier information |Non-covered or excluded coordination of benefits | Timely filing | Need to bill the liability carrier | Missing or invalid CPT or HCPCS codes | No referral on file.

Managing Claim Denials

If you can manage claim denials (most are related to coding or billing issues) efficiently, your practice will benefit financially. Some tips to manage claim denials include:

  • Appeal incorrect denials via phone, refiling, or an appeal letter.
  • Fight the denial by submitting your appeal within seven days of receiving the letter.
  • Study the dollar amount of the appeal to ensure that it is financially worthwhile.
  • Enlist the patient for help if necessary.
  • Know the carrier contract terms including covered services and compensation.

Examples of questions to ask include:

  • What is a causing the processing delay?
  • Why is the claim pending?
  • Who is the best person to talk with to address this claim?
  • How does this match up with the carrier contract?
  • What information is missing to resolve the claims issue? Who is the responsible party for submitting this? What is the deadline (if any)? 

Staff Knowledge

Make sure the accounts receivable team has absorbed continual updates regarding revenue cycle management such as the best ways to process claim denials while instituting a clean claim processing workflow. Make sure your front office team receives continual updates on how their workflow processes can prevent denials from the start - i.e. not obtaining correct insurance verification. 

Your persistent focus of preventing and resolving denied claims should result in removing barriers to receiving a legitimate payment or claims decision.

Success Stories


Average bill age when our office received: 180 days plus BALANCE: $ 1,233.00 PROBLEM: Claim denied needing primary EOB. SOLUTION: Claim billed to supplemental policy instead of MMAI policy which was effective for service date.
Average bill age when our office received: 180 days plus BALANCE: $ 2,176.00 PROBLEM: Claim denied because of no insurance coverage for service date. SOLUTION: Claim was filed to incorrect claims address.
Average bill age when our office received: 180 days plus BALANCE: $ 1,013.50 PROBLEM: Claim denied because of insurance ID mismatch. SOLUTION: Claim filed to traditional plan vs. community care.
Average bill age when our office received: 180 days plus BALANCE: $ 1,203.00 PROBLEM: Patient disputed charge/balance owed, comparing it to a similar past bill. SOLUTION: Explained itemized charges and balance owed because of deductible. Patient stated first time someone took the time to explain and set up a payment plan.
Average bill age when our office received: 180 days plus BALANCE: $ 1,007.50 PROBLEM: Denied by hospice as non-eligible benefit and Medicare as ID name mismatch. SOLUTION: Verified/corrected Medicare ID, name and date; confirmed hospice non-eligibility.
Average bill age when our office received: 180 days plus BALANCE: $ 1,305.00 PROBLEM: Denied no pre-authorization for service. SOLUTION: 3-way call with patient and insurance. No ER report on file when claim originally submitted. ER report since received.
Average bill age when our office received: 180 days plus BALANCE: $ 1,001.50 PROBLEM: Denied with "misrouted" and "claim not covered by payor". SOLUTION: 3-way call with patient and insurance. Claim was related to mental health so should have been filed through carve out policy.
Average bill age when our office received: 180 days plus BALANCE: $ 1,755.00 PROBLEM: No response from insurance after requested records submitted. Patient stated insurance paid. SOLUTION: Billing office did not receive/post insurance payment. Called insurance and records received but claims representative had not released for processing.
Average bill age when our office received: 180 days plus BALANCE: $ 4,540.50 PROBLEM: Multiple bills, same service dates as claims already paid. Denied due to no pre-authorization for service. SOLUTION: Call to insurance who verified no pre-authorization requirement. Two claims not found. To prevent duplicate denial upon resubmission, account rep notated resubmission for return transportation trip. Proof of timely filing submitted with claims.
Average bill age when our office received: 180 days plus BALANCE: $ 1,180.00 PROBLEM: Denied due to no pre-authorization for service. SOLUTION: 3-way call with patient and insurance. Claim should have been sent directly to IPA vs. umbrella insurance location.
Average bill age when our office received: 180 days plus BALANCE: $ 1,117.00 PROBLEM: Unpaid due to incomplete demographic information. SOLUTION: Contacted pick up and drop off locations. Sent release to obtain information and patient’s name misspelled.
Average bill age when our office received: 180 days plus BALANCE: $ 1,605.00 PROBLEM: Denied due to medical necessity. SOLUTION: 3-way call with patient and insurance. Spoke with multiple reps and received different answers including claim not found. Claim was found with no response from medical board. Patient had to submit medical records.
Average bill age when our office received: 180 days plus BALANCE: $ 1,007.50 PROBLEM: Denied multiple times as duplicate. SOLUTION: Located claim number ID, amount paid and date paid. Claim had already been paid in full but not posted.
Average bill age when our office received: 180 days plus BALANCE: $ 1,650.00 PROBLEM: No insurance on file. SOLUTION: Pick up location was state prison. Located inmate ID and could be billed to prison insurance as still within timely filing limits.
Average bill age when our office received: 180 days plus BALANCE: $ 2,295.50 PROBLEM: Denied as “forwarded to another entity for processing”. SOLUTION: Called insurance for medical group processing information. They did not have claim on file. Resubmitted with proof of timely filing.

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