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Common Code Denials

A troubleshooting list of common code denials/ alerts you may encounter on your Superbills.

Updated over a week ago

These Alerts/ Rejections/ Denials are listed in order of how frequently we see them occur.

*While we will not offer billing advice, what we can provide is some possible solutions to get these claims processed*

To search for your specific alert, use the Find function:

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Layperson's Terms

Possible Solutions*

ERA DENIAL - Payment for charges adjusted. Charges are covered under a capitation agreement / managed care plan.

This claim is covered by a capitation agreement. EITHER this claim has been capitated, OR this claim needs to be sent to the IPA with which the Capitation agreement has been signed

  • If the full amount has been capitated, you can "Settle (Capitation)" directly from the Claims Manager or the Patient's Claims page. This will remove the claim from the worklist, but will NOT remove any tags or alerts from the claim.

  • If a partial amount was capitated, create a Payment for the EOB/ERA, put the amount cap'd into the Allowed tab, and Settle to Capitation

  • If the alert came from a payer with which there is no capitation agreement, confirm to whom the payer subs out and transfer the claim to that payer

ERA DENIAL - Claim / service lacks information which is needed for adjudication. Check Remittance Remark Codes for details.

This generalized alert indicates that the claim has not been paid, and that the EOB/ERA will have another code on that claim line indicating the nature of the issue.

Find the claim's EOB/ERA and find the denial code associated with the claim

ERA DENIAL - Claim not covered by this payer / contractor. You must send the claim to the correct payer / contractor.

ERA DENIAL - Claim denied as patient cannot be identified as our insured.

This claim was submitted to the wrong payer

  • Review the patient's Eligibility for the DOS

  • Review the patient's insurance card

  • Contact the patient for up-to-date insurance information

  • Update to the proper payer

  • If payer is already proper, Appeal with proof of eligibility

[Primary Payer] payment date required

The Payer has been billed as Secondary and requires the EOB from the Primary

Appeal the claim, with the EOB attached.

ERA DENIAL - Expenses incurred after coverage terminated.

While the Payer has records of this patient, the policy under which the claim was submitted is no longer active

  • Review the patient's Eligibility for the DOS

  • Review the patient's insurance card

  • Contact the patient for up-to-date insurance information

  • Update to the proper payer

  • If payer is already proper, Appeal with proof of eligibility

  • At least one diagnosis pointer required.

  • Diagnosis A is required

No DX codes are present

Update and rebill

ERA DENIAL - Payment adjusted because the benefit for this service is included in the payment / allowance for another service / procedure that has already been adjudicated

  • This claim has been bundled and paid for in another billed procedure

  • OR this claim has been previously processed

  • Check the payer's claims portal to verify the status of the claim

  • Confirm all appropriate modifiers to denote Separately Identifiable Procedures have been used

ERA DENIAL - The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he / she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request a appeal, we will, upon application from the patient, reimburse him / her for the amount you have collected from him / her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment.

The patient's contract with this payer does not cover the service billed.

  • If this service should have been covered by the payer, you can Appeal it

  • If this service needs to be transferred to Patient Responsibility or Settled, you can do this via the Claims Manager or the patient's Claims page

ERA DENIAL - Benefit maximum for this time period or occurrence has been reached.

  • This is a one-time procedure that has been previously billed

  • This procedure has a limit on the number of times it can be billed, which has been surpassed

  • Confirm the CPT properly represents the nature of the claim

  • Confirm the authorization for this procedure is up-to-date

ERA DENIAL - Non-covered charge(s).

At least one procedure on this claim is not covered by the payer.

  • Check for any additional Remittance Codes for added context

  • Confirm no alternate codes should be used (particularly with Medicare for CMS guidelines)

Invalid Insured City/ Zip/ Insured Address...

The information indicated by the alert is mismatched between the Payer's records and what is stored in the Patient page

  • Confirm patient information has been input in the Patient page

    • Be sure to run the Verify Address tool; this checks against the USPS records for valid addresses

  • Ensure the Patient info matches what the Payer has on file

  • Once corrected, Rebill

ERA DENIAL - Payment denied / reduced for absence of precertification / authorization

The necessary Authorization is not present on the Claim

  • Add the Authorization and rebill

  • Get retro Authorization and rebill

At least one adjustment code required if amount paid is $0.00.

Within the Payment, there is no Adjustment Code within the second column of Adjusted

  • Post the Primary Payment and rebill

    • Note: only one primary payment can be posted

Adjustment amount required when adjustment code given.

Within the Payment, there is no Adjusted Amount within the first column of Adjusted

  • Post the Primary Payment and rebill

    • Note: only one primary payment can be posted

ERA DENIAL - Payment adjusted due to the impact of prior payer(s) adjudication including payments and / or adjustments

This claim was processed by the Payer as Secondary, who based their payment upon that of the Primary

Post payment as usual

Code 16 - Claim/encounter has been forwarded to entity. - Payer

The claim has been sent by the Payer to another Payer

  • On a Claim that has been Paid and forwarded, list the payer to whom it has been forward under the Crossover option within the Payment

  • On a claim that was directed to the first Payer improperly, no action is needed. You may, however, wish to update the Patient's Insurance Coverage to avoid misrouting in the future

Code 717 - Acknowledgement/Split Claim-The claim/encounter has been split upon acceptance into the adjudication system.This claim has been split for processing.

One or more lines of this claim have been split into separate claims to expedite processing

No action required - this claim has been/ will be processed.

ERA DENIAL - Duplicate claim / service.

This claim has already been received by the payer

  • No action required

    • If this alert comes after submitting an updated/ corrected claim, you may need to Appeal the rejection to elaborate upon the updates and request reprocessing

Code 496 - Submitter not approved for electronic claim submissions on behalf of this entity.Billing Provider

Electronic Claims Submission has not been enrolled for this payer

Enroll for Claims submission within the Practice Settings -> Insurance menu

ERA DENIAL - Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer).

ERA DENIAL - Secondary payment cannot be considered without the identity of or payment information from the primary payer. The information was either not reported or was illegible.

The Payer has been billed as Secondary and requires the EOB from the Primary

Appeal the claim, with the EOB attached.

ERA DENIAL - This service / equipment / drug is not covered under the patient's current benefit plan

The services billed are not covered by the payer

Contact the payer for more details

ERA DENIAL - Payment adjusted because the payer deems the information submitted does not support this many services.

This claim includes a service that can only be billed so many times (e.g. a patient's first visit with a provider, a yearly physical)

  • Update CPT and rebill

Duplicate adjustment code [].

A prior Payment includes the indicated Adjustment code more than once

Update and rebill

ERA DENIAL - Alert- You may not appeal this decision but can resubmit this claim / service with corrected information if warranted.

This claim cannot be Appealed, only Corrected

To resubmit, use the Superbill's Corrected Claim Info to designate the claim as Corrected, include the ICN from the EOB, and rebill

ERA DENIAL - The procedure code is inconsistent with the modifier used or a required modifier is missing.

The claim was submitted with an invalid Procedure/ Modifier combination

Update and rebill

ERA DENIAL - The time limit for filing has expired.

This claim was not submitted within the Payer's window of Timely Filing

If this Alert was the result of a resubmission on a claim that was originally filed timely, Appeal the claim with Claims History included

Diagnosis code pointer is missing or invalid

There is an error with the Dx fields

  • Confirm all Dx are correct

  • Confirm there are no more than 12 distinct Dx codes on the claim (as 1500s cannot support more than 12 distinct Dx codes)


The NPI under which the claim was processed is not deemed valid by the payer

  • Confirm the Enrollment is using the proper NPI (group vs provider)

Workers Comp/Auto claim ID required.

The patient's Workers Comp/ Auto claim ID number is required to process this claim

  • This information can be added to the patient's Authorizations (under "Insurance Coverage", click Auths)

  • Occasionally, the Member ID will need to be changed to the patient's SSN

Attachment may be required. Attach additional documentation if necessary and click [Save Claim].

Additional documentation is required on this claim.

  • At this time, additional documents cannot be transmitted with claims. If you have additional documentation you may have to print the claim and mail with your documents.

  • Alternatively, you might Appeal the claim with the documents attached.

  • Contact support if you have an instance where the document MUST be attached.

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