The claim was denied because the provider used the wrong diagnosis code. Who fixes it?
The provider, by filing a corrected claim; the insurer cannot change a provider's coding on its own. Your job is to get the itemised claim, spot the mismatch against the visit and the plan's rule, ask the provider's billing office in writing for the correction, and keep your own appeal deadline alive in case the corrected claim is late or denied again.
What to do, in order
- Step 1
Get the claim as billed
Ask the provider for the itemised claim with the diagnosis and procedure codes, and the insurer for the EOB with the reason code. Compare them with what actually happened at the visit and with the plan's rule (for example, preventive services need a screening code to be paid at no cost sharing).
- Step 2
Ask the provider for a corrected claim
In writing, with the claim number, the code billed, the code that matches the visit, and why. Ask for the date they refile and the confirmation number.
- Step 3
Tell the insurer a corrected claim is coming
One line to the insurer with the claim number, so it is not closed. If the corrected claim is denied, that is a new determination you appeal.
- Step 4
Appeal if the provider will not correct
Explain the mismatch in the appeal with the visit documentation. Insurers can pay on the record even when the provider will not refile, though it is harder.
The deadline that applies
Provider corrected-claim windows are set by contract, often 90 days to a year from the service. Your appeal window is at least 180 days from the denial (29 CFR 2560.503-1; 45 CFR 147.136). File the appeal before it closes even if the corrected claim is pending.
Calculate your date →Documents to gather
- The EOB with the reason code
- The itemised claim with codes
- The visit note or summary showing what was done
- Your written request to the provider and their reply
Go deeper
Related questions
Can the insurer just fix the code?
No. The provider certifies the claim and only the provider can correct it.
The provider says it billed correctly. Now what?
Ask which rule they applied and put both positions in your appeal with the visit note; the insurer decides on the record.
Will the provider charge me while this is pending?
Ask in writing for the account to be held; most will while a corrected claim is in process.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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