Omega ‘Healthcare ‘Non= Denials: AR SCENARIOS |. Claim not on file Claim in process Insurance i Claim eat eee an Beles inti Claim paid to patient a Claim processed towards capitation Claim processed towards deductible. . Claim processed towards offset. . Leave message PEN agReNE Denials: Normal Denials: 1. Claim denied for untimely filing 2. Claim denied as patient not eligible on DOS at the time of service.(Patient) . Claim denied as services not covered/non covered services. Claim denied as max benefits exhausted / services maxed. out(patient) Claim denied for no referral. Claim denied for missing/invalid authorization. Claim denied for COB.(Patient) Claim denied for primary insurance’s EOB. Claim denied as provider Non-par 0. Claim denied for pre-existing condition.(Patient) 31, Claim not paid as primary has exceeded maximum allowable Charges/ primary paid the maximum. 12. Claim denied as duplicate J mo coverage on DOS/ policy noteffective peNnagae Coding Denials: 1. Claim denied as dx/cpt are not consistent with ept/dx. 2. Claim pended / denied for additional information. . Claim denied as ‘mutually inclusive/ bundled/incidental. Claim pended/denied as submitted info is not valid/ incorrect. . Claim denied as medically not necessary Claim denied as not consistent with pt’s age or sex.(Patient) Claim denied as globally bundled sing or invalid. Claim denied as modifier is mis: 2 SNAOR Internal OMH-DOC-TRD-001-V1.1 Department of Training and Development Scanned with CamScanner