Denials: Top Reasons and Procedures

The Palmetto GBA Denial Resolution tool includes resources for resolving the top claim rejections and denial reasons. Save time and resources by looking here before you pick up the phone.

• Access denial reasons in plain language
• Scroll through the titles to locate your procedure
• Use the Palmetto GBA search engine to search by Remark code
• Also reference the Top Medical Denial Reasons job aide

Following are five of the top reasons that services submitted to Palmetto GBA are denied:

• The procedure code was invalid on the date of service.

Tip: Review and use the CPT and HCPCS Code Sets (PDF, 3.81 MB) effective for the billed date of service. 

• This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.

Tip: Review the current CPT Coding Manual and CMS coverage guidelines to determine the qualifying service/procedure that must also be submitted to Medicare.

• This service/equipment/drug is not covered under the patient's current benefit plan.

Tip: Review the CMS Medicare Learning Network Items and Services Not Covered Under Medicare Booklet (PDF, 1.15 MB)

• This care may be covered by another payer per coordination of benefits.

Tip: Medicare records indicate the patient has other insurance that may be responsible for the charge(s). Contact the patient or their responsible party for information regarding other insurance that may be liable for the charges related to the care provided.

• This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/ preventive exam.

Tip: Not all screening and preventive services a provider may feel are appropriate for a patient are covered under Medicare. Review the CMS Medicare Learning Network Medicare Preventive Services Publication for a list of Medicare covered screening and preventive services along with any specific coverage and billing guidelines.

Use the Denial Resolution tool to determine whether your denials for these services are correct or whether there are other steps you should take before submitting these claims.