Medically Not Necessity Denial
Medical necessity is defined as accepted health care services and supplies provided by healthcare entities appropriate to evaluating and treating
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AR Scenarios/Denial Management
ARCALLING SCENARIOS AND DENIAL MANAGEMENT AND ACTIONS
Maximum Benefit Exhausted/Met Denial.
Meaning: Some insurance companies limit the dollar amount they will pay per year for certain services or they limit the
Read MoreClaim denied for Prior authorization
Meaning: The insurance does not find authorization for the treatment denied. Claim Adjustment and Remark Codes: CO197 Precertification/authorization/notification absent. CO198
Read MoreDuplicate Denial Scenario
Meaning: The claim submitted has already been processed by the insurance. A similar service was performed for the same patient
Read MoreARCALLING 49 DENIAL SCENARIOS
1. Patient not on file or Patient cannot be identified as our insured (Adjustment reason code: 31) Check with the
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