In these challenging times, we have evaluated some of the top reasons for claim denials and identified resolution strategies to help your organization prevent claim rejections. Claim denials are common in medical billing and though it is near impossible to completely prevent denials, a well-orchestrated medical billing denial management plan can go a long way in significantly mitigating the impact of large volumes of claim denials.

This article discusses some of the most common reasons for claim rejections and offers strategic solutions for denial management in medical billing.

1. CO 11 – Diagnosis Code Does Not Match with the Procedure

This is one of the most prevalent denial codes where the claim is denied for the code not matching the medical service offered. The diagnosis code translates to the key description of the medical concern and it is essential that the diagnosis code is appropriate and relevant with the mentioned medical services.

It’s important that you cross-verify with your Medical billing and coding team to prevent denials happening from simple mistakes like typo errors or wrong diagnosis entered by mistake. Automated medical billing software programs allow you to identify such errors in claims, fix them in a jiffy and resubmit them for improved billing accuracies.

Denied claims also need to be internally verified to identify possible errors, so you can appeal the claim by sending all the relevant documents on patient’s diagnosis.

2. CO 27 – Insurance Expired

CO 27 occurs when medical services have been provided to a patient after the insurance expired and the claim was still submitted for the services. Ensure that you prevent such scenarios as these instances are hard to contest. This is where prior authorization and eligibility verification play a vital role by preventing unnecessary future confusions and facilitating transparent communications to stakeholders on patient responsibilities. It helps determine the insurance status and identify self-pay patients.

With a CO 27 occurrence, you can also backtrack information like the policy termination date to check if there was different insurance available for the patient at the time or the patient needs to be billed directly.

3. CO 22 – Multiple Insurers Involved

When the patient has multiple insurances, it is critical that the Medical billing and coding services team identifies the appropriate payer for the respective services offered—to prevent duplication of records. Ensure that you first submit claims to the primary provider followed by the other providers to prevent denials.

Top Reasons for Claim Rejections

Missing estimation of benefits

Primary insurer not identified correctly

The insurer has not been updated with additional insurance details

Also Read: 6 Key Strategies to Improve Denial Management Services in Healthcare Revenue Cycle

4. CO 29 – Late Submission of Claims

Payers have a time limit for claim submissions and it is essential that claims are processed and submitted within the stipulated time. A CO 29 denial code can instantly be identified as late submission claims post the time limit. Since the medical billing and coding services team works with multiple payers, it is crucial that they are updated on the deadlines to submit claims within the stipulated time.

Common Timeline Filing Deadlines to Remember

Aetna Hospitals: A year post service to submit claims Physicians: 90 days post service to submit claims	Cigna 180 days post service for out of network service providers 90 days post service for participating service providers
Tricare Claims to be submitted within a year of service	United Health Care Timeline filing limits made available in the agreement correctly

To prevent claim denials and improve reimbursements, it is essential that you stay on top of the procedures, timelines, latest regulatory changes, and denial codes. SolvEdge’s Medical billing service offerings including denial management services are strategically designed to meet the unique business needs of our clients. Our Medical billing team comprises revenue cycle experts including strategists, technologists, SMEs, certified coders and experienced professionals, who work together to accelerate revenue and efficiencies.

To learn more about how SolvEdge’s Medical Billing Services can help prevent claim denials and boost your bottom line, talk to our team.