Common categories
| Category | First things to verify |
|---|---|
| Eligibility / coverage | Member details, effective dates, plan, payer and date of service. |
| Authorization / referral | Requirement, authorization number, approved service, provider and dates. |
| Coding / modifier | Remit message, documentation, code validity, modifier support and coding review. |
| Duplicate | Prior claim history, original claim number, corrected-claim status and duplicate charge entry. |
| Medical necessity / coverage policy | Payer policy, diagnosis/service relationship and supporting documentation. |
| Coordination of benefits | Primary/secondary order, other coverage and prior payer processing. |
| Timely filing | Original submission date, acceptance evidence, payer filing limit and applicable exceptions. |
| Provider / enrollment | NPI, taxonomy, network/enrollment status, billing/rendering setup and date of service. |
Administrative vs. clinical review
Some denials can be resolved by correcting verified administrative information. Others require coding, clinical documentation, authorization or provider-enrollment review. Billers should route issues to the correct team instead of making unsupported changes.
Investigation sequence
- Read the payer response.
- Identify the affected claim or service line.
- Check claim history and previous submissions.
- Verify the source data related to the denial category.
- Review payer requirements and deadlines.
- Select the supported next action.
- Document what was found and what was submitted.
Quick knowledge check
A duplicate denial appears. What should you check before resubmitting?
Claim history, previous payer processing, corrected-claim status and whether the charge was entered twice.
An authorization denial appears. What should you verify?
The authorization requirement, number, approved dates/services/provider and payer records.
Should billing change a diagnosis to overcome a medical-necessity denial?
No. Any coding change must be supported by documentation and appropriate coding review.
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Training note: This material is for education and staff development. Payer rules, plan benefits, coding guidance, contracts and regulations change; learners should verify current requirements with authoritative payer, CMS and coding resources when performing real billing work.