Reasons Why Claims Are Not Being Processed

If a healthcare patient’s claims are denied, not only will they often wonder why claims are not being processed, but they may still submit claims that are inaccurate. Here are some of the common reasons that claims are denied.

Top Reasons Why A Claim Is Not Being Processed

Missing Or Incomplete Patient Info

An incredible portion of claim denials are administrative or clerical in nature and originate at the front desk. This means things like patient data oversights, such as a missing patient subscriber number, missing date of birth, and incorrect insurance eligibility are all routine reasons that a claim is denied. 

Basic Claim Form Errors

A huge portion of claim rejections is known to be caused by “simple errors” in either the patient data or in the procedure codes. This can be something as simple as a misplaced letter in the last name, or a patient ID number having two digits transposed. These errors are usually very quick and easy errors to fix, but they stretch out the revenue cycle, so they should be avoided if at all possible. 

Lack Of Official Documentation Supporting The Claim

Claims that have a component of medical necessity will need documentation or records that support that designation. In situations like this, the payer will often require additional support documents that not only illustrate medical necessity but also support the level of service.

Insufficient Medical Necessity

Even when substantial amounts of documentation and medical records are provided, occasionally a payer will simply decide that a procedure or treatment isn’t medically necessary. This can be a difficult situation for everyone involved, but in some cases, it can be avoided. 


The best way to fight insufficient medical necessity denials is to have good communication between your clinicians and coding staff. When a claim is denied, for this reason, the doctor’s office or provider may be forced to absorb the treatment cost, or they may be able to collect the full amount from the patient, which isn’t very likely. 

Pre-Authorization Or Pre-Certification Was Not Obtained

There are many situations that warrant getting pre-authorized to perform some type of care. Knowing which insurers require pre-authorization and what they require to authorize coverage is essential for your coding and billing team. Depending on what coding or billing software is used, there may even be built-in measures for highlighting certain procedures and special insurers.

Claims Filed After Deadline

With all of the different insurers out there, it’s no surprise that many of them have different deadlines for submitting claims, and have varying degrees and policies for exceptions when deadlines are missed. Some payers can fix a missed submission with a quick phone call, while others will require a more clerical and administrative fix by having you fill out some paperwork to get the issue fixed.

The Provider Used Was Out-Of-Network

Insurance companies and their networks can change drastically from one year to the next, and while many patients don’t realize it, this includes the various doctors and healthcare providers they have partnered with. To be sure that claims, benefits, and payments are made in full for your treatment and doctor’s appointments, use a doctor or facility that is in-network. While this may not mean that everything is covered, significantly more of the services that you need will be able to be obtained in this way. 

Prevent More Denials With AMS Solutions

Your billing matters and claims denied for simple and preventable mistakes. Ensure that your medical billing support is all properly trained in the methods that your biggest payers require by partnering with AMS Solutions.

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