Why medical claims get denied, and how to fix each reason

By Arovia RCM · Published 2026-10-25

1. Coverage was inactive or the details were wrong

The patient's plan ended, changed or was entered with a typo. Fix: check eligibility before the visit and confirm the member ID, date of birth and plan at check-in.

2. Prior authorization or referral was missing

Some services need approval before they are performed. Fix: keep a list of services that need approval for each major payer, and check status before scheduling. See our prior authorization service.

3. Coding errors

The procedure and diagnosis codes do not match, or a required modifier is missing. Fix: review common denied codes, train the team and audit a sample of claims each month.

4. The claim was filed too late

Every payer has a time limit for filing. Fix: send claims within days of the visit, and track any claim that has not been accepted by the payer.

5. Duplicate claim

The same service was submitted twice. Fix: check claim status before resubmitting, and use corrected-claim steps when the payer asks for them.

6. Patient or provider information does not match

A name, date of birth, provider number or practice address differs from what the payer has on file. Fix: keep demographic data clean and confirm provider details with each payer.

7. Medical necessity was not shown

The payer does not see enough in the record to justify the service. Fix: make sure notes support the diagnosis and the service, and send records quickly when asked.

8. Out of network or provider not enrolled

The provider is not credentialed with the plan on the date of service. Fix: confirm enrollment before a new provider sees patients. See credentialing and enrollment.

Find your own top reasons

Pull a report of denials from the last 90 days and group them by reason code. Fix the top three first. This usually does more than working claims one by one. If you do not have time, our denial management service does this every week and tells you what to change.

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