Permission Slip Problems
This denial occurs when required approval was not obtained before services were performed.
What is a prior authorization denial?
The payer determined the service was not clinically necessary.
What is a medical necessity denial?
This denial occurs when a claim is submitted after the payer's filing deadline.
What is a timely filing denial?
This denial occurs when the patient did not have active coverage on the date of service.
What is an eligibility denial?
Clinical criteria not met
What is "the payer believes the documentation doesn't support the service"?
The payer may request this number to verify services were approved.
What is an authorization number?
These guidelines are commonly used to evaluate inpatient admissions.
What are MCG and InterQual?
Providers should retain these as proof of claim submission.
What are clearinghouse reports?
Insurance follow-up staff use this process to verify coverage before services are rendered.
What is eligibility verification?
Services exceed benefit limitations
What is "the plan has reached its maximum allowed visits or units"?
Emergency services are often exempt from this requirement.
What is prior authorization?
The payer believes the patient's condition could have been treated at a lower level of care.
What is an inpatient medical necessity denial?
This document may overturn a timely filing denial if it shows the claim was submitted on time.
What is proof of timely filing?
Coverage through more than one insurance plan may require this review.
What is coordination of benefits?
Provider failed to obtain authorization.
What is "approval was required before services were performed"?
This type of denial may occur when services exceed the approved units or visits.
What is an authorization denial?
Documentation supporting severity of illness helps prevent this denial.
What is a medical necessity denial?
The number of days allowed for claim submission is called this.
What is the timely filing limit?
The subscriber ID and patient demographic information help prevent these denials.
What are eligibility denials?
Documentation does not support the billed code.
What is "the medical record doesn't justify the coding submitted"?