What is Denials Management in RCM?
Denials management is a critical aspect of revenue cycle management (RCM) that focuses on identifying, addressing, and preventing the denial of claims by insurance payers. When a claim is denied, it means the insurer has rejected the request for reimbursement for services provided. Effective denials management involves understanding the reasons for these denials, implementing strategies to address them, and resubmitting claims with the necessary corrections. This process helps healthcare providers recover lost revenue and maintain financial health.
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What Problems Can We Solve For You?
Frequent Claim Denials: Claims can be denied for various reasons such as missing information, coding errors, or lack of authorization. These denials can lead to significant revenue loss and disrupt the cash flow of healthcare providers. Pure RCM assists in identifying the root causes of denials, implementing corrective actions, and preventing future occurrences by ensuring that claims are accurately and comprehensively submitted.
Complex Resubmission Process: Resubmitting denied claims can be a cumbersome and time-consuming process. It requires thorough documentation, adherence to payer-specific guidelines, and timely follow-up. Pure RCM streamlines this process by leveraging our expertise in denials management, ensuring that resubmitted claims are corrected and submitted promptly to maximize reimbursement opportunities.
Benefits of Pure RCM’s Services
Why Choose Pure RCM?
Effective denials management is essential for maintaining the financial health of healthcare providers. By understanding common denial codes and implementing robust resubmission strategies, providers can recover lost revenue and improve cash flow. Pure RCM Health & IT Consultancy offers comprehensive services to address denials, ensuring that claims are accurately submitted and reimbursed promptly. Our expertise in navigating complex payer requirements, coupled with our commitment to compliance and continuous improvement, makes us the ideal partner for managing your claim submissions and denials.
Most Common Denial Codes in Abu Dhabi
| Denial Code | Description | Notes |
|---|---|---|
ELIG-001 | Patient is not a covered member | Claim is submitted for Member number "123". However, member number "123" is not found in payer’s database. Hence, the claim for this member would not be eligible for payment. |
ELIG-005 | Services requested/performed after the last date of coverage | The submitted authorization request/claim for member has a card expiry date of 31/12/2023; all services requested/provided after 01/01/2024 will not be eligible for approval/payment. |
ELIG-007 | Services requested/performed by a non-network provider | If an authorization request/claim is submitted and the provider is not contracted with a specific plan or payer on the requested/claimed service dates, then such authorization requests/claims would not be eligible for approval/payment on direct billing. |
AUTH-001 | Prior approval is required and was not obtained | Outpatient MRI claim requires pre-approval. However, if no pre-approval was requested or was requested and denied, then such claims would not be eligible for payment. |
CLAI-012 | Submission not compliant with contractual agreement between provider & payer | It can include a variety of denials such as coding errors, incorrect claim type, incorrect encounter type, New / Established Code Mistakes, etc. |
CLAI-016 | Incorrect billing regime | fee-for-service claim reported as a DRG claim. For example, in the case of inpatient dental or day care claims which should be billed as fee-for-service but are submitted as DRG claims. |
Most Common Denial Codes in Dubai
| Denial Code | Description | Notes |
|---|---|---|
BENX-001 | Service/Medication is above AED threshold | Claim denied because the service or medication cost exceeds the allowable AED threshold. |
CLAI-013 | Missing an Observation (Dental Tooth #) | Claim denied due to missing essential dental information such as the tooth number. |
CODE-001 | Missing, incomplete or invalid principal diagnosis | Claim denied because the principal diagnosis is missing, incomplete, or invalid. |
CODE-002 | Missing, incomplete or invalid service code | Claim denied due to missing, incomplete, or invalid service code. |
CODE-006 | Diagnosis is inconsistent with the procedure | Claim denied because the diagnosis does not match the procedure performed. |
CODE-016 | Activity/diagnosis inconsistent with Service | Claim denied because the activity or diagnosis is inconsistent with the provided service. |
MNEC-007 | Service is not clinically indicated based on good clinical practice, without additional supporting documentation | Claim denied as the service is not deemed clinically necessary without further documentation. |
NCOV-009 | Dental treatments are not covered | Claim denied because the dental treatments are not covered under the patient’s insurance plan. |
NCOV-010 | Elective procedure is not covered | Claim denied because the elective procedure is not covered under the patient’s insurance plan. |