Overview
What are Code Denials?
Code denials are rejection or denial messages returned by payers or clearinghouses indicating why a claim was not accepted or paid. Understanding these codes helps you resolve issues and resubmit claims successfully.How to Use This Guide
These alerts, rejections, and denials are listed in order of frequency. To search for your specific alert, use your browser’s Find function:- Windows: Ctrl + F
- Mac: Command + F
While we will not offer billing advice, we can provide possible solutions to get these claims processed.
Common Denials Reference
| Rejection/Denial | Explanation | Possible Solutions |
|---|---|---|
| Payment adjusted - capitation agreement | This claim is covered by a capitation agreement | If fully capitated, “Settle (Capitation)” from Claims Manager. If partial, create a Payment with amount in Allowed tab and Settle to Capitation. If wrong payer, transfer to correct payer. |
| Lacks information for adjudication | Generalized alert - check Remittance Remark Codes | Find the claim’s EOB/ERA for the specific denial code |
| Patient cannot be identified as insured | Claim submitted to wrong payer | Review eligibility, insurance card, contact patient, update payer, or appeal with proof of eligibility |
| Primary Payer payment date required | Billed as Secondary, requires Primary EOB | Appeal the claim with EOB attached |
| Expenses incurred after coverage terminated | Policy is no longer active | Review eligibility, contact patient, update payer, or appeal with proof of eligibility |
| Diagnosis pointer required | No DX codes present | Add diagnosis codes and rebill |
| Benefit included in another service | Claim bundled or previously processed | Check payer portal, confirm appropriate modifiers used |
| Does not substantiate level of service | Patient’s contract doesn’t cover this service | Appeal if should be covered, or transfer to patient/settle |
| Benefit maximum reached | Procedure limit exceeded | Confirm CPT is correct, check authorization is current |
| Non-covered charge | Procedure not covered by payer | Check remittance codes, confirm correct codes used |
| Invalid address/city/zip | Information mismatch with payer records | Verify address with USPS tool, ensure patient info matches payer records, rebill |
| Absence of precertification | Authorization not on claim | Add authorization and rebill, or get retro authorization |
| Adjustment code required | No adjustment code in payment | Post primary payment and rebill |
| Duplicate claim | Already received by payer | No action required; if corrected claim, appeal with explanation |
| Submitter not approved | Not enrolled for electronic claims | Enroll in Practice Settings → Insurance menu |
| Time limit for filing expired | Missed timely filing window | If originally filed timely, appeal with claim history |
| Diagnosis code pointer missing/invalid | Error with DX fields | Confirm DX codes correct, ensure no more than 12 distinct codes |
| Billing NPI not on file | NPI not valid with payer | Confirm enrollment uses correct NPI (group vs provider) |
| Workers Comp/Auto claim ID required | Claim ID needed | Add to patient’s Authorizations; sometimes Member ID needs to be SSN |
| Attachment may be required | Additional documentation needed | Print and mail claim with documents, or appeal with documents attached |