Billing, coding and paperwork

Guides

• Coding and billing errors

  How to tell if a denial comes from a coding or billing mistake. Learn who must fix it, how to get the codes, correct the claim and ask the plan to reprocess it.

• Not a covered benefit

  What to do when a plan says a service is not a covered benefit or is excluded. Check the plan document and the law, and see which arguments can still work.

• Timely filing, coordination of benefits and eligibility denials

  What to do when a claim is denied as filed too late, because another insurer pays first, or because the plan says you were not covered. See who has to fix each one.

• When coverage is cancelled retroactively

  What federal rules say about a plan cancelling your coverage back in time. A rescission is different from a cancellation for unpaid premiums. Here is how to appeal.

Tools

• Tool

  Denial reason finder

  Match the wording on your letter to a denial reason, see who must act first, and open the right playbook.

Letters and scripts

• Letter or script

  Appeal: coding error and reprocessing

  Asks your plan to reprocess a claim that was denied because of a billing or coding mistake, after your provider has corrected and resubmitted it.

• Letter or script

  Appeal: filed too late

  Asks your plan to accept a claim it called late, by showing when it was first sent, quoting the plan's own filing rule, and asking it to apply any exception it contains.

Denial reasons

• Denial reason

  Another insurer is primary

  The plan says another insurance plan must pay first, or it wants the other plan's decision before it pays. Only you know all your coverage, so you usually have to sort out the order and tell both plans.

• Denial reason

  Bundled or included in another service

  Your plan folded the charge for one service into the payment for another from the same visit, so it paid nothing for it. Often the provider's billing office can correct the claim, so start there.

• Denial reason

  Coding or billing error

  The claim itself has a wrong code, a wrong detail or a missing item. Your provider's billing office usually has to correct it and send it again. You help by asking for the codes, checking them against your records and following up.

• Denial reason

  Coverage not active

  The plan says you were not covered on the date of service. Find out why, because a plan or employer error, a missed premium and a cancelled policy each have a different fix, and the deadline to act may be short.

• Denial reason

  Coverage rescinded

  Your plan says it is cancelling your coverage retroactively, as if it never existed, because of your application. Federal rules allow that only for fraud or an intentional misrepresentation of a material fact, with 30 days' written notice.

• Denial reason

  Dental or vision boundary

  Your medical plan says the care belongs to your dental or vision plan, and the dental or vision plan may say it belongs to medical. Get both answers in writing and compare each to the plan's own wording.

• Denial reason

  Duplicate claim

  The plan thinks it already received or paid this claim. Check your Explanation of Benefits for the first claim. If the services are separate, your provider's billing office has to show the plan that.

• Denial reason

  Filed too late

  The plan says the claim reached it after its filing deadline. If your provider was supposed to file it, the late filing is usually the provider's problem to fix. Ask for proof of when the claim was sent.

• Denial reason

  More information needed

  The plan has not decided yet, or it denied because something it asked for did not arrive. Read exactly what it wants, find out who holds it, and send it in a way you can prove. The plan must give you time to respond.

• Denial reason

  No referral

  Your plan says a referral was needed before you saw a specialist and none was on file. Sometimes the referral was given but never recorded, or the paperwork can be fixed, so call both offices before you appeal.

• Denial reason

  Preventive care billed as diagnostic

  You went for a recommended screening or checkup that should have cost nothing, but the claim was coded as diagnostic, so you were charged. Sometimes a corrected claim from the provider fixes it.

• Denial reason

  Visit or benefit limit reached

  Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.

• Denial reason

  Waiting period or pre-existing exclusion

  Your plan says the care came before your coverage kicked in, or that it excludes a condition you had beforehand. Check the dates first, because many of these are date errors, and ask which rule the plan used.

Programs and services

Run by other organizations.

• Program or service

  Community Health Advocates (New York)

  New York State's designated consumer assistance program: a free helpline and local advocates for New Yorkers with any kind of coverage, plus do-it-yourself appeal guides. Open to New York residents only.

  From Community Service Society of New York

• Program or service

  FAIR Health Consumer cost estimates

  A nonprofit's tools for estimating what providers charge and what insurers pay in your area, plus insurance basics. Useful evidence in an out-of-network payment dispute. It does not file appeals or negotiate for you.

  From FAIR Health