How to avoid Appeal in Medical Claim Denial [Tips]

Avoid Appeal in Medical Claim Denial will allow the service to process as expected, reducing the need to make changes after the claim has processed. 

In this post, we are going to see how to avoid appeal in Medical Claim Denial. Here we go, 

Avoid Appeal in Medical Claim Denial
How to avoid Appeal in Medical Claim Denial [Tips]

Tips to Avoid Appeal in Medical Claim Denial:

 Should be intimately familiar with local coverage determinations (LCD)

 Should be with familiar with the national coverage determinations (NCD)

• If necessary, add a modifier to the services. Failure to add a modifier would result in rejection.

• Documenting a repeat or duplicate service to reflect this is a separate and distinct service. Failure to document a repeat or duplicate service will result in denial of service.

• Provide the supporting documents with the claim, if a certain modifiers [e.g] Modifier 52 (or) Modifier 22 are appended to the service (or) if the LCD or NCD suggests that the documents are needed. Failure to request the documentation would result in a denial.

• Compliance with supporting documentation requests. Failure to meet with the request would result in a denial.

• The supporting documentation must include the signature of the rendering physician. Failure to have a valid provider signature will result in denial.

• Include a concise description of the unlisted procedure code (NOC code) or the "not otherwise marked" code. Failure to describe the NOC or other scenarios listed below will lead to denial.

• If Medicare is a secondary payer (MSP), the claim should include details from the primary insurance carrier. Failure to include this information will lead to denial.

Please verify that all below details relating to the service are accurate to avoid Appeal in Medical Claim Denial. The right information helps the service perform as planned; removing the need to make changes after the claim has processed, 
  1. NPI of Billing Physician
  2. Assignment or Non-assignment of claim
  3. Health Insurance Number (HIC) of the beneficiary
  4. Zip Code of the place of service
  5. All related diagnosis reported with the highest degree of specificity
  6. NPI of Referring Physician
  7. Date of service
  8. Place of service
  9. Procedure code
  10. Modifiers when applicable
  11. Number of services (s)
  12. Billed amount for each service
  13. NPI of Rendering Physician
  14. Clinical Laboratory Design Adjustment Number (CLIA) for laboratory facilities
  15. The Date last saw/X-ray date, original treatment period for Podiatry, Physical Therapy, and Chiropractic Services.
  16. Primary payer data

The conclusion to Avoid Appeal in Medical Claim Denial:

The LCD is a recommendation by the Medicare insurance whether to cover a particular item or service. LCDs provide accurate and appropriate details and are administrative and instructional resources that support you in the filing of correct claims for reimbursement.

LCDs can be visible on the website of the Novitat Solutions Medical Policy Center. Be acquainted with the National Coverage Determinations (NCD).

The National Coverage Determinations Manual specifies how different medical items, facilities, medication procedures (or) technology will be payable under Medicare.


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