Common Claim Denial reasons
The number one cause for a denial is that a patient is ineligible for services on the Date of Service on the claim.
AZZLY has automated Eligibility which automatically runs at a preset time and on a schedule selected by the facility.
Other common reasons for denials are:
A simple omission, such as spelling of patient name, gender or date of birth, can lead to a costly denial. AZZLY is setting up a process, that matches the patient information to Eligibility check information.
This happens when a similar or equivalent claim is sent because of a clerical error or overlap in office duties.
When manually billing, using two screens eliminates this issue. Search for the patient in the Claims screen on the left. Verify that the Dates of service you are billing for have not already been sent before creating a new claim in the screen on the right.
Improper or outdated HCPCS/CPT/DSM 5 or ICD-10 codes.
AZZLY updates the HCPCS/CPT/DSM 5 and ICD-10 codes for you automatically, requiring no user action.
Prepare a list of your payers and their Timely Filing Deadlines. Use the Claims screen and filter by Aging Status and compare this list to the aged claims.
|Payer||Timely Filing Deadline|
|Medicare||365 days from date of service|
|Anthem||90 days from date of service|
|Cigna||90 days from date of service|
|UnitedHealthcare||90 days from date of service|
|Humana||180 days from date of service (physicians)
90 days from date of service (ancillary providers)
|Aetna||120 days from date of service|
|Tricare||365 days from date of service|
Service is not covered.
A patient’s coverage may have been terminated or their maximum benefit has been met. Frequent eligibility checks in AZZLY should eliminate this issue.
Out of network.
Some plans require doctors and practitioners to be “in-network” for coverage.
Verifying In or Out of Network coverage up front with AZZLY eligibility checks eliminates this issue.
Problems with modifiers.
Errors can result from submitting invalid modifier combinations. Many invalid modifier combinations can be avoided with additional training for billing staff.
Prior authorization required.
Assure that all Utilization Review staff is provided a Tip Sheet with a list of Payers and services that require authorizations.
AZZLY Rize is an all-in-one electronic health record (EHR) and revenue cycle management (RCM) solution for behavioral health and addiction treatment providers. AZZLY provides configuration and hands-on training and implementation, as well as 24/7 support from U.S.-based staff. AZZLY’s billing system includes a Chargemaster and autogeneration of claims. Clients using AZZLY’s RCM services have a 98% first-time pass rate. Take the first step to speak with one of our experts by filling out this short form.
About the Author
A. Joyce Wagner, Chief Operations Officer
Director of Revenue Cycle Management (RCM) Services & Operations
Joyce Wagner has over 30 years experience in operations, compliance and accounting. Starting in 1985, Joyce was an executive member of a New York regional brokerage firm with AZZLY Founder and CEO Coletta Dorado. In their time, the brokerage grew from five key management team members to over 600 independent advisors throughout the USA and sold to a major bank for $100 million in 2001. Joyce did not come from healthcare originally, and this gives her a unique perspective on medical billing. Joyce has applied best practices of accounting and compliance to medical billing and reports that is unique to the industry. Joyce has created and introduced a training manual for all billers to become experts.