Coding or billing error

What it means

The plan is not disputing your care. The claim has a problem: a wrong code, a wrong detail about you, a diagnosis that does not fit the service billed, charges split that belong together, or a charge for something you did not receive. The Arthritis Foundation lists nine common errors of this kind, including transposed numbers, a duplicate charge, upcoding (billing a more expensive service than you received) and incorrect balance billing.

If the plan never processed the claim, it is usually called a rejection rather than a denial. Nothing is final yet. The provider fixes the claim and sends it again. If the plan processed the claim and refused to pay, that is a denial with appeal rights.

Who has to act first

Your provider’s billing office corrects the claim and resubmits it. You make that happen.

• Ask the plan for the codes. A non-grandfathered plan must give you the diagnosis code, the treatment code and their meanings on request. Asking is not an appeal.
• Ask the provider for an itemized bill and your billing records. A provider must act on a request for your own records within 30 days, with one extension of up to 30 more days if it explains the delay in writing.
• Ask both for the last date a corrected claim can be accepted. We could not confirm that limit, so confirm it with the plan and the billing office.

If the plan sent a denial notice, your appeal deadline is at least 180 days after you receive it for a job-based plan or a non-grandfathered individual plan (check the date on your notice, which controls). Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. If the correction is slow, file the appeal anyway to protect your rights.

Arguments that work

• The codes do not match what happened. Compare the codes on your Explanation of Benefits (EOB) and itemized bill with your visit notes.
• A preventive visit coded as a diagnostic one. A non-grandfathered plan must cover recommended preventive services without cost sharing. Consumer sites list screening-versus-diagnostic coding as a common problem, so ask your provider to check it.
• Charges that belong together were billed apart, or a charge is for care you did not get. The itemized bill shows it.
• A wrong detail about you. A misspelled name, birth date or member number can stop a claim. Ask for it to be corrected.
• The plan gave a code, not a reason. A non-grandfathered plan’s notice must contain the denial code and its meaning. If it does not, ask in writing.

Evidence to gather

• The EOB and any denial notice (you).
• The diagnosis and treatment codes with their meanings (the plan, on request).
• An itemized bill (your provider).
• Your visit notes and records (your provider).
• The corrected claim’s date and new claim number (your provider).
• A log of your calls (you).

What to send

Send the billing office a short written request that lists the error, says what it should read, and asks for confirmation when the claim is resent. Ask the office to pause collection on the account while the plan reprocesses it; it is not required to, and an unpaid bill can go to collections, so ask before you withhold any payment. Send the plan a copy and ask it to reprocess when the corrected claim arrives. If the plan still denies, appeal with the corrected claim and your records.

When this is not worth an appeal

If you have only a rejection and no denial notice, there is nothing to appeal yet. Have the provider fix and resend the claim, and watch your calendar in case a denial notice follows.