Common Code Denials | Elation Billing PMS Help Center

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*

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REJECTION/ DENIAL	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	While the Payer has records of this patient, the policy under which the claim was submitted is no longer active	Review the patient's Eligibility for the DOS Review the patient's insurance card Contact the patient for up-to-date insurance information Update to the proper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)
Code 21 - Missing or invalid information. BILLING NPI IS NOT ON FILE BILLING NPI IS NOT AUTHORIZED FOR TAX ID	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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