Top Reasons for Claim Denials and Rejections

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 List of CPT/HCPCS Codes effective for the billed date of service. 

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

Tip: Review the current CPT Coding Manual and CMS coverage guidelines to determine the qualifying service or 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).

• 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.