What is a frequency-limit denial?

A frequency-limit denial occurs when the payer determines that a service was performed more often than allowed under its benefit, medical policy, or coding rules.

Frequency edits can be based on time period, diagnosis, service type, screening schedule, benefit limits, or clinical policy.

The denial should be reviewed to determine whether:

• The service was truly performed too soon
• A prior service was incorrectly attributed to the patient
• A modifier or diagnosis changes the policy application
• An exception exists based on medical necessity

Coverage frequency rules are payer-specific and can change over time.

• Frequency rules are payer-specific.
• Review prior claims and service dates.
• Some exceptions may exist.
• Do not change dates or codes to bypass the edit.

A screening service denies because the payer says it was performed too soon. The AR representative reviews the patient's prior paid history and confirms whether the payer's frequency calculation is correct.

• Appealing without checking prior service history.
• Changing diagnosis merely to bypass the limit.
• Assuming all payers use the same frequency.

Verify prior service history and the exact payer rule.