7 Red Flags That Get Claims Rejected (And How to Avoid Them)

Introduction

Most insurance claims are first screened by software, not humans. Certain "red flags" trigger an automatic rejection before an adjuster even sees your case. If you know what these triggers are, you can avoid them.

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The 7 Red Flags

1. Timing Gaps

Filing a claim months after the event without a valid explanation often triggers a "Late Filing" rejection. Fix: File within 30 days of the incident.

2. Out-of-Network Surprises

Using an in-network hospital but an out-of-network anesthesiologist is a common trap. Fix: Always request "All In-Network" providers in writing during pre-op.

3. Procedure-Diagnosis Mismatch

If the medical code for the treatment doesn’t logically "match" the diagnosis code, the system flags it. Fix: Review the codes with your doctor’s billing desk.

4. Duplicate Filings

Submitting the same claim twice because you didn’t hear back can cause both to be flagged as fraudulent. Fix: Call to check status instead of refiling.

5. Lack of Prior Authorization

For non-emergencies, skipping the "Permission" step is a guaranteed "No." Fix: Get your auth number before the appointment.

6. Missing Coordination of Benefits (COB)

If you have two insurance plans but haven’t told them which is "Primary," claims will bounce between them indefinitely. Fix: Update your COB status annually.

7. Unbundled Charges

Providers sometimes bill for parts of a procedure separately to get more money. Insurers hate this. Fix: Request an itemized bill to ensure "Global Billing" is used.

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Conclusion

By avoiding these seven red flags, you move your claim to the "Fast Track" for approval. Knowledge of the system is your best defense against unnecessary delays.