Reasons for Claim Denial

Phone: (718) 670-2574
Call to speak to a client representative for questions regarding claim denial.

Commonly encountered reasons for the denial of submitted claims

  • Tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicitly authorized by statute. These include exams required by insurance companies, business establishments, government agencies, or other third parties.
  • Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statute.
  • Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified non-physician practitioner) through documentation in the physician’s office may result in denial.
  • A claim for a test for which there is a national coverage or local medical review policy will be denied as “not reasonable and necessary” if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim.
  • If a national or local policy identifies a frequency expectation, a claim for a test that exceeds the expectation may be denied as “not reasonable and necessary”, unless it is submitted with documentation justifying increased frequency.
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