Family practices see the same denial patterns again and again. The fastest path to better collections is fixing root causes at the front desk, in charge capture, and in your claim edit rules. Use this guide as a working playbook.
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Quick Reference Table
| Denial | What it means | Fast fix | Prevention tip |
|---|---|---|---|
| 1) Information missing or invalid | Required data absent or wrong | Correct demographics, insurance ID, modifiers, resubmit | Build EHR required field checks and clearinghouse edits |
| 2) Eligibility inactive on date of service | Coverage lapsed or plan changed | Verify current plan, update payer, resubmit | Verify eligibility 48 hours before visit and same day |
| 3) Coordination of benefits needed | Another plan is primary | Collect other insurance, update COB, resubmit | Intake script to ask secondary coverage every visit |
| 4) Timely filing expired | Filed after payer deadline | Request reopening if allowed, appeal if proof exists | Post payer deadlines by desk and monthly aging sweep |
| 5) Noncovered service | Benefit exclusion or plan rules | Bill patient if allowed, or adjust if prohibited | Estimate benefits and disclose financial responsibility |
| 6) Bundled into another service | Service included in another code | Remove unbillable line, add correct modifier if appropriate | Charge capture tip sheets for common bundles |
| 7) Level of service not supported | Documentation does not match code level | Downcode or submit appeal with notes | E M audit program and short provider training |
| 8) Prior authorization missing | Plan required authorization | Obtain retro auth if possible, or appeal | PA matrix by payer and service, previsit checklist |
| 9) Referral required | Plan requires PCP or in plan referral | Obtain referral or appeal where allowed | Referral tracking log and scheduling prompts |
| 10) Duplicate claim | Same service already processed | Void duplicate or wait for original to post | Batch controls and claim scrub rules |
| 11) Diagnosis and procedure mismatch | Code pairing not payable | Correct ICD and CPT pairing, resubmit | LCD and payer policy checks in scrubber |
| 12) Place of service or taxonomy error | POS or taxonomy does not match site | Correct POS or taxonomy, resubmit | NPI, taxonomy, POS master file review |
| 13) Rendering or billing provider issue | NPI, group, or credentialing problem | Update NPI, paneled status, resubmit | Credentialing calendar and CAQH hygiene |
| 14) Modifiers missing or invalid | 25, 59, 51, 95, 24 errors are common | Apply correct modifiers with notes, resubmit | Modifier rules by visit type tip sheet |
| 15) Global surgery period conflict | Minor procedure within global window | Use correct modifier or defer to global rules | Scheduler flags for global periods |
| 16) Telehealth billed incorrectly | Wrong POS or telehealth modifier | Correct POS 02 or 10 and modifier 95 if needed | Telehealth cheat sheet by payer |
| 17) CLIA or lab billing error | Test requires QW or CLIA number | Add QW, include CLIA, resubmit | Lab charge capture template and EHR defaults |
| 18) Vaccine billing error | Wrong admin codes or stock type | Fix admin code, units, NDC, resubmit | Vax day checklist and inventory linkage |
| 19) Out of network limitation | OON benefits restricted | Verify benefits, collect at time of service, appeal if underpaid | Insurance verification notes and OON policy signage |
| 20) Medical records requested | Payer needs notes before payment | Submit notes promptly and track | Documentation upload SOP within 72 hours |
1) Information Missing Or Invalid
What it means
Claims reject for bad demographics, subscriber ID, group number, or missing data such as modifiers.
Where it shows up
New patients, plan changes, staff turnover, rushed intake.
How to fix now
- Validate patient and subscriber IDs against the card.
- Correct modifiers and diagnosis pointers.
- Resubmit electronically with corrected data.
How to prevent
- Make key fields required in the EHR.
- Add clearinghouse edits that stop claims with blank plan IDs or invalid member formats.
- Train front desk to scan both sides of cards and to confirm the plan name, not just the payer brand.
2) Eligibility Inactive On Date Of Service
Fix now
Run real time eligibility, update to the current plan or route to the correct payer, then resubmit.
Prevent
Eligibility checks 48 hours previsit and same day, plus a script that asks, “Has your insurance changed since your last visit?”
3) Coordination Of Benefits Needed
Fix now
Ask for other coverage, update COB in payer portal if allowed, resubmit.
Prevent
Add a COB question to every intake and include it on your patient portal check in.
4) Timely Filing Expired
Fix now
If you have clearinghouse acceptance proof within deadline, send appeal. If not, request reconsideration only if payer policy allows.
Prevent
Post each payer filing limit, run a weekly no acknowledgment report, and escalate any claims not accepted within seven days.
5) Noncovered Service
Fix now
Confirm benefit exclusion, issue a patient statement if permitted by contract and disclosure, or adjust if not billable.
Prevent
Estimate out of pocket for services known to be excluded. Use plan specific financial consent language at check in.
6) Bundled Into Another Service
Fix now
Remove the unbillable component or add the correct modifier when distinct and medically necessary.
Prevent
Create a family practice bundling tip sheet for E M plus common procedures, injections, and tests.
7) Level Of Service Not Supported
Fix now
Compare documentation to code selection, downcode if needed, or appeal with supporting notes.
Prevent
Quarterly E M audits, five charts per provider. Share quick wins, such as capturing time based coding accurately.
8) Prior Authorization Missing
Fix now
Attempt retro authorization within the plan window, or appeal with clinical rationale if appropriate.
Prevent
PA matrix by payer for imaging, sleep studies, certain injections, and DME. Scheduler check before appointment.
9) Referral Required
Fix now
Obtain referral retroactively if plan allows, otherwise appeal if criteria met.
Prevent
Referral tracker tied to scheduling and a day before visit cross check.
10) Duplicate Claim
Fix now
Void or withdraw the duplicate. Do not carpet bomb resubmissions.
Prevent
Lock batches after submission and require a brief note when a claim is resubmitted to avoid duplicates.
11) Diagnosis And Procedure Mismatch
Fix now
Use payer policy and NCD or LCD guidance to correct ICD and CPT pairing.
Prevent
Scrubber rules that look for common unpayable pairings in preventive visits, vaccines, rapid tests, and minor procedures.
12) Place Of Service Or Taxonomy Error
Fix now
Correct POS 11 for office, POS 02 or 10 for telehealth when appropriate, ensure taxonomy matches the rendering provider.
Prevent
Master file review whenever you add a location or a new provider.
13) Rendering Or Billing Provider Issue
Fix now
Confirm NPI, group NPI, and that the provider is credentialed with that payer and location.
Prevent
Credentialing calendar with effective dates, CAQH updates every quarter, and a go live checklist before scheduling a new provider.
14) Modifiers Missing Or Invalid
Fix now
Apply 25 for significant, separately identifiable E M with a minor procedure, 59 or X modifiers for distinct services when appropriate, 95 for telehealth, 24 for unrelated E M during a postop period.
Prevent
One page modifier cheat sheet by visit type and a second review step for any E M plus procedure claims.
15) Global Surgery Period Conflict
Fix now
If a visit is unrelated to the procedure during the global, apply 24. For a procedure on the same day, ensure correct E M modifier 25 when appropriate.
Prevent
Scheduler flags when a patient is in a global period and prompts staff on eligible billing combinations.
16) Telehealth Billed Incorrectly
Fix now
Use correct POS for telehealth based on payer guidance and add modifier 95 when required. Ensure the service is eligible for telehealth.
Prevent
Telehealth grid by payer that includes eligible CPT codes, POS, modifiers, and patient cost share notes.
17) CLIA Or Lab Billing Error
Fix now
For waived tests, add QW if required and ensure your CLIA number is on file.
Prevent
Default QW on applicable CPTs, CLIA number stored at the billing provider profile, and a lab specific charge capture template.
18) Vaccine Billing Error
Fix now
Correct vaccine product, admin code, units, NDC, and lot as required by the payer. Distinguish VFC versus private stock.
Prevent
Immunization clinic checklist that ties inventory to codes and requires admin code selection for each vaccine.
19) Out Of Network Limitation
Fix now
Verify OON benefits and collect higher cost shares at check in. Appeal if the plan should have paid at in network rates under specific contract terms.
Prevent
Clear OON policy signage, estimate benefits, and add OON alerts in the schedule.
20) Medical Records Requested
Fix now
Submit notes within three business days through the payer portal or fax route and track the request to completion.
Prevent
Documentation upload SOP with ownership, due dates, and confirmation of receipt logged in the claim notes.
Denial Management Workflow You Can Adopt This Week
- Triage queue
Split daily denials into three bins: fix and resubmit under 5 minutes, needs provider input, needs appeal packet. - Appeals library
Maintain payer specific templates for insufficient documentation, medical necessity, level of service, and coordination of benefits. Store in a shared drive and version them quarterly. - Weekly root cause huddle
Review top five denial reasons, agree on one front desk fix, one coding fix, and one claim edit fix. Assign owners and due dates. - KPIs to monitor
- First pass resolution rate above 90 percent
- Denial rate below 8 percent for family practice
- Days in AR under 35
- Percentage of claims touched more than once under 10 percent
FAQs
Under 8 percent is a solid target. Track both initial denial rate and final denial write off rate.
Touch same day for clearinghouse rejections and within 3 business days for payer denials. Appeals within the payer window.
High dollar, near timely filing limit, and quick wins such as eligibility and COB.
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