85–90% of all claim denials are preventable (MGMA; Deloitte 2024). Yet 50–65% of denied claims are never reworked — meaning most preventable denials become permanent revenue loss. This checklist covers every checkpoint from eligibility through secondary claim submission. Use it as a pre-submission audit before your biller releases a claim batch.
85–90%
of all denials are preventable (MGMA)
27%
of denials trace to eligibility errors (MGMA)
$25–$118
cost to rework each denied claim (HFMA)
$262B
claims denied annually in the US (HFMA)
Stage 1: Active Coverage Verification
Perform 48–72 hours before scheduled visits. Real-time at check-in for urgent/walk-in. Use your PM system's real-time eligibility (RTE) tool — do not rely on the patient's insurance card alone.
Policy is active — not terminated, suspended, or pending renewalConfirm active status, not just "policy exists." Retroactive terminations are common for self-employed patients and recent job-changers.
Coverage effective date confirmed — visit date falls within benefit period
Patient has not aged into Medicare (if patient approaching age 65)Medicare becomes primary automatically at 65. Missing this is a CO-109 denial (claim not covered by this payer).
Subscriber ID (member ID) — exact match to insurance recordNo transpositions. Leading zeros and trailing letters are common drop errors.
Group number confirmed (for employer-sponsored plans)
Legal name matches insurance record exactlyHyphenated names and suffixes (Jr., Sr.) are common mismatch sources. One character off = CO-16 denial.
Date of birth exact matchA single-digit transposition causes instant CO-16 denial. Verify against government ID at first visit.
Relationship to subscriber confirmed (self, spouse, dependent)Affects coordination of benefits and claim routing. Misclassification causes CO-22 denial.
Stage 2: Benefits Verification
In-network vs. out-of-network status for YOUR NPI with THIS payerCredentialing with a payer does not guarantee in-network status at every location. Verify the rendering provider NPI and service location NPI are both in-network.
Copay amount for this visit typeOffice visit, specialist, preventive — different copay tiers. Collect at time of service.
Deductible: annual amount, amount met YTD, remaining balance
Out-of-pocket maximum: annual amount, amount met YTD
Coinsurance percentage (patient share after deductible)
Coordination of Benefits: is this primary or secondary? Is there another active policy?Ask every patient at every visit. Job changes, spouse's open enrollment, and Medicare aging all change COB mid-year.
Referral required: Yes/No — if yes, is referral on file and valid?
Specialist access: does plan require PCP referral for specialist visits?
Behavioral health carved out? Many plans use a separate behavioral health payer
Vision/dental carve-out verified (for practices billing crossover services)
Stage 3: Prior Authorization
PA is the fastest-growing denial category. 20–25% of all denials trace to missing or invalid prior authorization. PA-related denials have grown >20% in two years. Physicians average 39 PA requests/week (AMA 2025).
Does this CPT code require PA under this specific payer's policy?Do not rely on memory. Check the payer's published PA requirement list. PA requirements change quarterly.
Valid, unexpired authorization number is on file
Auth covers the correct date(s) of serviceAuth must not be expired or future-dated. Date range must include the actual visit date.
Auth is tied to the correct rendering provider NPIAuth obtained under one provider's NPI cannot be used for a different provider — common error in group practices.
Auth covers the correct number of units/visitsDo not exceed authorized units. Track unit consumption across dates of service.
Auth is linked to the correct diagnosis codeAuth obtained for one diagnosis does not automatically cover a different diagnosis code — even for the same patient and procedure.
Stage 4: Provider Credentialing & NPI
Rendering provider NPI is active in NPPES (nppes.cms.hhs.gov)CMS deactivates NPIs after 5+ years of no claims. Verify annually or after any inactive period.
Group billing NPI is active and rendering provider is associated to it
Taxonomy code on claim matches taxonomy code enrolled with this payerWrong taxonomy code = CO-4 or CO-16 denial. Especially critical for multi-specialty groups.
Provider is actively credentialed (enrolled) with this specific payerCredentialing with an insurance company does not automatically mean enrolled. Confirm PTAN for Medicare.
Service location NPI is enrolled at this addressMulti-location practices: each physical address may need separate enrollment per payer.
No lapsed or pending re-credentialing that could block paymentTrack re-credentialing expiration dates. Most payers require re-credentialing every 2–3 years.
Ordering/referring provider NPI confirmed and enrolled (for referral-based claims)
Stage 5: Coding & Claim Accuracy
Coded to highest level of specificity (7th character where required)Fractures, injuries: laterality and encounter type (initial/subsequent/sequela) required. Unspecified codes trigger CO-11 denial.
Laterality specified (left/right/bilateral) wherever applicable
Active vs. history codes correct (Z codes for history, not active disease codes for resolved conditions)
Primary diagnosis supports the procedure billed (medical necessity)ICD-10 must be on the LCD (Local Coverage Determination) covered diagnosis list for the CPT being billed.
NCCI (National Correct Coding Initiative) edit check run for all code pairs
Modifier -25 used correctly: separate, significant E/M on same day as procedure — distinct documentation required
Modifier -59 used correctly: distinct procedural service — only when no other modifier is more specific (XE, XS, XP, XU preferred)
Modifier -51 applied to secondary procedures (not primary), where required
Modifier -57 applied: decision for surgery made at E/M visit on day of or day before major surgery
Global surgery period check: no E/M billed during 10-day (minor) or 90-day (major) global period without appropriate modifier (-24, -25, -57, -79)
Modifier -TC/-26 not double-billed to same payer (technical component and professional component)
Place of Service code correct: POS 11 (office) vs. POS 22 (outpatient hospital) vs. POS 02/10 (telehealth)POS errors directly affect reimbursement rates. POS 11 vs. POS 22 can be a 40–60% payment difference.
Stage 6: Timely Filing & Secondary Claims
Claim submitted within payer's timely filing window (see table below)100% of timely filing denials are preventable. Track filing deadlines by payer in your PM system.
Clearinghouse acceptance confirmation received (accepted ≠ paid — track both)
Claims submitted within 48 hours of date of service (best practice; reduces filing risk)
| Payer | Timely Filing Window | Critical Note |
|---|
| Medicare FFS | 365 days from DOS | Federal statute; no exceptions |
| Medicare Advantage | 365 days (most plans) | Verify individual plan — some are shorter |
| Medicaid FFS | 90 days–12 months | STATE DEPENDENT — verify your state |
| Aetna | 120 days (commercial); up to 1 year (employer/MA) | Verify plan documents |
| UnitedHealthcare | 90–180 days (commercial); up to 1 year (MA) | Verify plan documents |
| Cigna | 90–180 days (commercial) | Verify employer plan documents |
| Humana | 90 days | Strictest major commercial payer |
| BCBS | 60 days (WY) to 2 years (AL) | Must verify state-specific BluePlan |
| Tricare | 365 days | Federal program |
| Workers' Comp | 30–180 days | STATE DEPENDENT — verify state law |
Sources: CMS MLN Matters MM3557; BellMedEx Timely Filing Guide; HFMA 2025
Primary EOB received and primary payment amounts confirmed before secondary submission
CO-45 (contractual adjustment) or PR amounts properly allocated
Secondary claim submitted within secondary payer's timely filing windowWindow is measured from primary payment date OR original DOS, depending on payer. Confirm which applies.
Primary payer ID and claim number included in secondary claim COB fields
Crossover claims (Medicare → Medicaid): confirm whether crossover is automatic or requires manual submission in your state
Key Statistic: 27% of claim denials stem from eligibility-related errors — the single largest preventable denial category (MGMA). 35% of denials trace to authorization or eligibility failures combined (AMA). Implementing Stages 1–3 of this checklist alone eliminates the majority of preventable revenue loss.
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