Insurance Denial Codes: What They Mean and How to Appeal

medical necessity: Services not deemed a medical necessity by the payer.

medical necessity: The diagnosis is not covered.

medical necessity: Information submitted does not support this many or this frequency of services.

experimental investigational: Procedure or treatment deemed experimental or investigational.

formulary pharmacy: Service, equipment, or drug not covered under the current benefit plan.

documentation: An attachment or other documentation is required to adjudicate the claim.

documentation: Claim or service lacks information, or has a submission or billing error.

prior authorization: Precertification, authorization, or notification absent.

prior authorization: Precertification or authorization exceeded.

coordination of benefits: Care may be covered by another payer per coordination of benefits.

duplicate: Exact duplicate claim or service.

eligibility: Expenses incurred after coverage terminated.

timely filing: The time limit for filing has expired.

non covered: Non-covered charge or charges.

wrong payer: Claim not covered by this payer or contractor.

benefit maximum: Benefit maximum for the time period has been reached.

coding: The diagnosis is inconsistent with the procedure.

bundling: Payment is included in the allowance for another service.

prior authorization: The authorization number is missing, invalid, or does not apply to the billed service or provider.

prior authorization: Services were denied at the time authorization or precertification was requested.

medical necessity: Charges do not meet the payer's qualifications for emergent or urgent care.

medical necessity: Treatment was deemed to have been rendered in an inappropriate or invalid place of service.

non covered: Non-covered service because it is a routine, preventive, or screening exam.

documentation: The related or qualifying claim or service was not identified on this claim.

coding: The diagnosis was invalid for the date or dates of service reported.

coding: The procedure code was invalid on the date of service.

coding: The procedure code is inconsistent with the modifier used, or a required modifier is missing.

eligibility: The patient cannot be identified as the payer's insured.

coordination of benefits: The impact of prior payer adjudication, including payments and adjustments.

bundling: This procedure is not paid separately.

procedural: Plan procedures were not followed.

eligibility: Expenses incurred prior to the start of coverage.