Omega
‘Healthcare
‘Non= Denials: AR SCENARIOS
|. Claim not on file
Claim in process
Insurance i
Claim eat eee an Beles inti
Claim paid to patient a
Claim processed towards capitation
Claim processed towards deductible.
. Claim processed towards offset.
. Leave message
PEN agReNE
Denials:
Normal Denials:
1. Claim denied for untimely filing
2. Claim denied as patient not eligible on DOS
at the time of service.(Patient)
. Claim denied as services not covered/non covered services.
Claim denied as max benefits exhausted / services maxed. out(patient)
Claim denied for no referral.
Claim denied for missing/invalid authorization.
Claim denied for COB.(Patient)
Claim denied for primary insurance’s EOB.
Claim denied as provider Non-par
0. Claim denied for pre-existing condition.(Patient)
31, Claim not paid as primary has exceeded maximum allowable Charges/ primary paid
the maximum.
12. Claim denied as duplicate
J mo coverage on DOS/ policy noteffective
peNnagae
Coding Denials:
1. Claim denied as dx/cpt are not consistent with ept/dx.
2. Claim pended / denied for additional information.
. Claim denied as ‘mutually inclusive/ bundled/incidental.
Claim pended/denied as submitted info is not valid/ incorrect.
. Claim denied as medically not necessary
Claim denied as not consistent with pt’s age or sex.(Patient)
Claim denied as globally bundled
sing or invalid.
Claim denied as modifier is mis:
2
SNAOR
Internal OMH-DOC-TRD-001-V1.1
Department of Training and Development
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