Claim Denials

Why would a colonoscopy and endoscopy be denied reimbursement if pre-authorization was obtained and medical necessity was proven?

re: Claim Denials

What was the reason for the denial? Did the scheduled date change with no notification to the payer?

re: Claim Denials

No. The procedure took place on the scheduled date. When querying the insurance company, their only response was that the provider was missing information. All information was checked and verified, and the claim was resubmitted. Again, claim was denied for the same reason.

re: Claim Denials

The denial EOB should indicate what information was missing. Check every entry carefully including modifiers and CCI edits. Review exactly what was called in to obtain authorization. If still not clear, ask to speak with a supervisor/manager at the payer.

re: Claim Denials

Also make sure that the diagnoses are correct. I know that when I worked in the hospital setting, sometimes the diagnoses were entered wrong and insurance would deny.