What is the best way to handle denials? 


There are a few steps to take when addressing denials. Here they are:

  1. Review the EOB/EOR in detail to determine the reason for denial. Payors include denial codes next to line items that are denied. This provides information to you as to the reason for denial. Most of the time it is well explained. The next step you take to handle the denial will be determined by the reason the service(s) were denied.

  2. If after reviewing the EOB/EOR,

    • you are still unclear on the reason for denial, you must call the payor directly to inquire. Be sure that you have all of the claim information at your fingertips when making the call.

    • you believe that the service(s) should have been covered, you will do the following: 
      Review the Verification of Benefits to confirm that you have a record of coverage for the service(s) in question. 

    • If not, you follow the EOB/EOR instructions.

      The non-covered balance must either be written off or will become patient responsibility. If there is evidence of coverage, you move on to the next step.

  3. Review your claim to ensure that there wasn't an error in coding or billing. Though this isn't an all-inclusive list, common coding/billing errors are:
    1. Box 14 (Date of Current) is too old      

    2. Not enough diagnosis to support the services rendered and billed for

    3. Incorrect use of code(s) or modifier(s) for the claim     
    4. Incorrect or insufficient diagnosis pointing  
    5. Use of codes that are not permitted to be reported together

  4. If the issue is one where there was an error in coding and billing, a corrected claim must be created. You will append the CC modifier (Corrected Claim) to the line items that have been corrected. Once complete, you will resubmit your claim.

  5. If the issue is one where service(s) were denied for something such as "not medically necessary" or "incidental to the primary procedure", you must do the following:

    1. Make sure your claim is correct

    2. Review documentation to ensure that you have fully documented and supported the services billed.

    3. Once you have completed both a. and b. directly above, you will copy the supporting documentation and resubmit the claim. When doing this, a short narrative or further explanation may be necessary to best communicate with the payor. Be sure that if this is done, it is signed and dated appropriately using the current date.

  6. Finally, a brief statement on an office letterhead should be included as well. This is simply stating that in your practice review of the claim and coverage details, you do have evidence of coverage and support of medical necessity. On this letterhead, kindly ask claims processors to review the information included and reconsider the claim for appropriate processing and payment.

Please note that this is not a detailed description regarding handling denials as there are many variables for receiving a denial. It would be unwise to resubmit a claim to request reconsideration and payment if your documentation doesn't support medical necessity. It may be necessary to seek help when handling a denial. Please reach out to ChiroCode as needed for this and other denial scenarios if guidance is needed for your practice.