Most Frequently Reported Claims Denial Reason Codes by Payer

Here are the most frequently reported claim adjustment reason codes (CARC) for a claims denial by payer, according to data from the American Medical Association's National Health Insurer Report Card for years 2008-2013 that address denials.

Aetna — CARC 96: Non-covered charge(s). (37.2% of denials)

Anthem — CARC 204: Service/equipment/drug is not covered under the patient’s current benefit plan. (29.4% of denials)

Cigna — CARC 96: Non-covered charge(s). (29.2% of denials)

Health Care Service Corporation — CARC 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. (40.4% of denials)

Humana — CARC 125: Submission/billing error(s). (23.7% of denials)

Regence — CARC 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. (29.4% of denials)

UnitedHealthcare — CARC 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. (30.2% of denials)

Almost 4% of all claims are denied on first submission, according to a Medical Economics report citing data from MGMA's "Cost Survey Report: 2013 Report Based on 2012 Data." While this overall number has declined in recent years, representatives of CMS and MGMA have said they expect to see a significant increase in claims denials in near future, driven in part by next year's transition to ICD-10.

By outsourcing billing to an electronic medical billing company such as PGM Billing, providers will see immediate and substantial financial benefits. An experienced company like PGM will increase a provider's revenue by boosting collection rates, reducing denials and delays in payment, and allow a provider to save money in billing staff salaries and benefits, training, and IT equipment and software. So if you're looking for a chiropractic billing service, an immunology billing agency or help with ASC medical billing, contact PGM today!


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