Claim lacks information needed for adjudication.
Common Root Cause:
A missing modifier, NPI, or patient subscriber information/data element.
How to Fix:
Review the RARC remark on the ERA, correct the missing field, and resubmit the claim.
Care may be covered by another payer (COB Dispute).
Common Root Cause:
Insurer believes patient has alternate primary insurance, or secondary payer coordination of benefits forms are out of date.
How to Fix:
Obtain primary EOB, update Coordination of Benefits (COB) form, and rebill secondary with primary attachment.
Timely filing limit has expired.
Common Root Cause:
Claim was submitted past the payer's allowed timely filing window (commonly 90, 180, or 365 days from date of service).
How to Fix:
Verify original submission date. Submit proof of timely filing via clearinghouse receipt and file a formal appeal.
Services not deemed medically necessary by payer guidelines.
Common Root Cause:
Diagnosis code (ICD-10) does not support the procedure (CPT) according to LCD/NCD national coverage policies.
How to Fix:
Add supporting diagnosis, attach detailed medical records, and cite the payer's LCD guidelines in an appeal.
Service is bundled/included in the allowance of another procedure.
Common Root Cause:
Billing two services together that fall under NCCI bundling edits, causing one to be considered incidental.
How to Fix:
Review NCCI edits. If clinically justified, apply modifier 59/XE/XP/XS/XU to separate billing.
Precertification / prior authorization was not obtained.
Common Root Cause:
Payer policy requires prior auth for CPT code, but claims were submitted without authorization code or screening.
How to Fix:
If authorization was obtained, add code to Box 23. If not, appeal requesting retroactive approval with clinical support.
Duplicate claim submission.
Common Root Cause:
Claim submitted multiple times without waiting for processing, or appealing a claim without a corrected claim modifier.
How to Fix:
Verify eligibility, route to correct payer, check enrollment, or resubmit with frequency code 7 for correction.
Non-covered service under patient's policy guidelines.
Common Root Cause:
CPT code billed represents an exclusion under the patient's benefits package (e.g. experimental or cosmetic).
How to Fix:
Verify eligibility in advance. Transfer balance to patient billing *only* if an ABN or waiver was signed.
Benefit maximum / visit limit has been reached.
Common Root Cause:
Patient exceeded annual allowed visits for specialty (e.g. 20 physical therapy or chiropractic visits per calendar year).
How to Fix:
Submit to secondary insurance if available, or transfer responsibility to the patient if a waiver was signed on intake.
Add-on code cannot be billed / allowed alone.
Common Root Cause:
Billed an add-on CPT code without the corresponding base primary code on the same date of service/claim sheet.
How to Fix:
Identify the base code (e.g., primary procedure), add it back to the claim file, and submit as a corrected claim form.
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