74 matching questions.
Provider demographic changes should be reported through the payer’s required update process so enrollment, directory, claims, and payment records remain accurate. The team should…
I would first determine whether authorization was actually required, whether one existed, and whether the payer allows retroactive authorization or an appeal based on emergency, m…
A duplicate claim denial occurs when the payer believes the same or substantially similar service has already been submitted or processed.
A medical necessity denial occurs when the payer determines that the billed service does not meet its coverage criteria for being reasonable, necessary, or appropriate for the pat…
I would compare the denied claim with prior claim history to determine whether it is truly duplicate, a valid repeat service, or a corrected claim that was submitted incorrectly.
I would first confirm the actual payer effective date and whether the provider, group, and location were correctly enrolled. For pre-effective-date services, I would review the pa…
Retroactive enrollment is a payer-approved enrollment effective date that reaches back before the final approval or processing date. It may be requested when payer rules allow and…
A bundling denial occurs when the payer considers one billed service included in another service and therefore does not allow separate payment.
I would verify the code pair, current edit, modifier indicator, documentation, and payer policy before deciding whether the denial is correct or whether a supported modifier or ap…
Credentialing and enrollment problems can create unpaid or denied claims when the payer does not recognize the provider, group, location, or effective date. These balances age in…