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.

provider eligibility: The services were not provided by a network or primary care provider recognized under your plan.

documentation: Information requested from the patient, insured, or responsible party was not provided, or what was provided was insufficient or incomplete.

prior authorization: A required referral for the service was missing.

medical necessity: The coverage or program guidelines for this service were not met.

eligibility: The health plan ID number and the patient or policyholder name submitted on the claim do not match the records the insurer has on file.

bundling: Payment was reduced or adjusted under the payer's rules for multiple or concurrent procedures, such as multiple surgeries, multiple diagnostic imaging, or concurrent anesthesia.

coding: The procedure or revenue code billed does not match what the payer considers appropriate for the patient's age.

procedural: The information used in a previous processing of this claim appears to be incorrect, so the claim was adjusted or denied.

provider eligibility: Payment is denied because this type of provider is not allowed to perform or bill for this service under your plan.

provider eligibility: The rendering provider is not eligible to perform the specific service that was billed.

eligibility: The expenses were incurred during a period when your coverage had lapsed and was not active.

documentation: Information requested from the billing or rendering provider was not provided, or was not provided in time, to process the claim.

bundling: This procedure or procedure and modifier combination is not compatible with another procedure billed for the same day under correct coding rules such as the National Correct Coding Initiative.

prior authorization: The services were not authorized by the network or primary care provider as the plan required.

coordination of benefits: The patient responsibility amount left by a prior payer, such as a deductible, coinsurance, or copay, is not covered by this payer.

coding: The procedure code or type of bill does not match the place of service where the care was reported as given.

coding: The procedure code does not match the provider's type or specialty as identified by their taxonomy.

coding: The payer says the diagnosis code on the claim does not match what is medically expected for someone of the patient's age.

coding: The payer says the diagnosis code on the claim is not consistent with the type of provider who submitted it.

benefit maximum: The payer says the patient has reached the lifetime maximum dollar amount or service limit that the plan will pay for this benefit.

prior authorization: The payer says the services were not provided or authorized by the network or designated providers the plan requires the patient to use.

procedural: The payer says it will not cover charges from multiple physicians or surgical assistants for this particular case.

procedural: The payer adjusted or denied the claim because of an error in how it was submitted or billed.

medical necessity: The payer decided that the information submitted does not support the level of service that was billed.

medical necessity: The payer decided that the information submitted does not support the length of service that was billed.

eligibility: The patient has not met the eligibility requirements needed for the plan to cover this claim.

benefit maximum: The claim exceeds the contracted or maximum number of hours, days, or units this provider may bill for the period, and it is not specific to the patient.

benefit maximum: Your plan applied a coverage or program guideline limit, meaning the service went past a cap, frequency rule, or benefit threshold your policy allows.

bundling: Your plan does not separately cover these outpatient services because they were performed within a window before or after a related inpatient stay and are treated as part of that stay.

fee schedule: Your charge was more than the fee schedule, maximum allowable, or contracted amount the plan permits, so the difference is written off.

contractual: These charges are already paid for under a capitation agreement or managed care plan, so they are not paid again on a separate claim.

patient responsibility: The amount the patient must pay toward covered services before the plan begins to share costs for the year.

patient responsibility: The patient's share of the allowed amount, charged as a percentage after the deductible has been met.

patient responsibility: The fixed per-visit or per-service fee the patient owes under the terms of their plan.

liability other: Payment for this service was sent directly to you, the insured, or another responsible party instead of to the provider.

contractual: The service is not payable under the terms of the managed care contract between the provider and the plan.

contractual: This is a claim-specific negotiated discount that the provider agreed to take off the charge under their contract with the payer.

liability other: This is an adjustment for a mandated federal, state, or local law or regulation that is not already covered by another code.

liability other: Your plan says this is a work-related injury or illness, so it should be billed to the Workers' Compensation carrier instead of your health insurance.

liability other: Your plan says this injury or illness is covered by a liability carrier, so that carrier, not your health insurance, is responsible for the cost.

liability other: Your plan says this injury or illness is the responsibility of a no-fault carrier, such as auto no-fault coverage, rather than your health insurance.

contractual: Your plan applied a managed care withholding, an amount held back from the provider's payment under the provider's managed care contract.