Denial Reasons and Actions Needed to Resolve

Summary

Claim denials delay payment and disrupt cash flow. This guide outlines common denial reasons and how to prevent them so your claims process smoothly. This includes the following: 

• Time limit for filing

• Duplicate claims or services

• Missing documentation

• Exceeded billable time / max units

• Bundled services

• Max benefits reached

• Workers’ compensation or accident-related injuries

• Eligibility issues

• Coordination of benefits (COB)

The Time Limit for Filing Has Expired

This denial means the claim was submitted after the payer’s allowed filing deadline. The payer will not process or pay the claim.

To ensure timely payment:

1. Submit all claims to Zaya within 30 days of the date of service (DOS).

2. If there is a justifiable reason for late submission, email support@zayacare.com for review.

Claims received after payer filing limits are at risk of nonpayment.

Duplicate Claim or Service

This denial means the payer flagged the claim as a duplicate. The claim may have already been processed or is under review.

To prevent this:

1. Submit each claim to Zaya only once.

2. If you need to correct a submitted claim, do not resubmit it.

3. Email support@zayacare.com with the correction details, and our team will handle it.

Missing Documentation

This denial indicates required documentation was missing, incomplete, or not submitted on time.

Once Zaya submits a claim, the payer may request additional records. If that happens, we will contact your practice, or pull the records from your EMR if you have provided us with access. 

To avoid delays:

1. Upload requested documentation promptly when contacted.

2. Ensure records are complete and accurate before submission.

Outstanding medical record requests tied to denials or payer follow-ups must be addressed within 90 days of DOS. After 90 days, requests will be archived.

Workers’ Compensation or Accident-Related Injuries

This denial means the patient’s primary medical insurance does not believe it is responsible for payment due to a work-related or accident-related injury.

Using injury codes as the primary diagnosis often leads to rejections because payers prefer functional limitation codes as the primary diagnosis.

Injury codes typically begin with “S” or “T.” These codes are generally acceptable in secondary, tertiary, or quaternary positions.

To reduce denials:

1. Use functional limitation codes as the primary diagnosis when appropriate.

2. Ensure clinical documentation clearly reflects the cause of the condition and the need for treatment.

3. Review the full set of injury codes before submission.

Eligibility

This denial means the health plan indicates the patient is not eligible for coverage.

To resolve:

1. Contact the patient to verify current insurance information.

2. Confirm that you have the most up-to-date insurance details on file.

3. Email support@zayacare.com with the updated information so we can determine next steps.

Coordination of Benefits (COB)

Insurance companies require patients to confirm whether they have other active coverage. If the patient does not complete this step, payment may be delayed or denied.

To resolve:

1. Instruct the patient to call the phone number on the back of their insurance card.

2. Have the patient provide all requested information to the health plan.

3. After the patient completes this step, email support@zayacare.com so we can resubmit the claim.

Exceeded Billable Time / Max Units

Most payers, including Aetna, UHC, and Medicare, cap therapy services at 4 billable units per patient, per day (approximately 60 minutes of treatment). Claims exceeding this limit are often denied for exceeded allowable time or max units reached.

These denials are typically not recoverable unless medical necessity is clearly supported. Zaya will only act on this denial category if you request it and provide supporting documentation. If no action is requested, the denial will be written off.

To prevent this:

1. Plan sessions around 4 units unless the patient’s condition clearly requires more time.

2. If additional time is clinically necessary, document why skilled therapy beyond 4 units is required (complexity, comorbidities, plateau, etc.).

3. Submit a Letter of Medical Necessity and supporting notes through the Zaya portal or email support@zayacare.com if an appeal is needed.

4. Review payer policies for unit limits before scheduling extended sessions.

5. Check payer policies for unit limits before scheduling longer sessions.

   • UnitedHealthcare Policy – Max Frequency per Day
   • Medicare Local Coverage Article (LCA) – Therapy Cap Guidance
   • Aetna OfficeLink: Expanded Modality Limit (pg 3)    

Common CPT codes affected include: 97032, 97110, 97112, 97116, 97124, 97530, 97533, 97535, 97760, 97761, and 97763.

Bundled Services

Some CPT codes are considered inclusive (bundled) when billed on the same date of service. In these cases, the payer will not reimburse both services separately.

For example, certain manual therapy or supervised modality codes may be considered part of a primary therapeutic procedure.

To prevent bundling denials:

1. Do not bill mutually exclusive codes on the same date of service.

2. Use modifier 59 only when services are clearly separate in time or body region.

3. Clearly document distinct, timed interventions in your note (for example: manual therapy to lumbar spine, 10 minutes; therapeutic exercise to lower extremity, 30 minutes).

4. Review the modifier 59 guidance article to confirm which codes may bundle.

Max Benefits Reached

This denial occurs when the patient has exhausted their visit or dollar limit under their benefit plan. Additional sessions are not covered unless an authorization or exception is approved.

To prevent this:

1. Verify remaining visit limits before scheduling additional sessions. Running an eligibility check in the Zaya portal can help confirm this.

2. If the patient is nearing their limit, discuss options early.

3. Request an extension authorization when medically necessary.

4. Inform the patient if future visits may become self-pay.

5. Submit updated progress notes and the plan of care when requesting visit extensions.