RCM Tip
Five Things to Check Before Submitting Any Claim
None of these are sophisticated. All of them are common.
Most rejected claims fail on something small. These five checks catch a large share of them, and none require clinical judgment.
One: patient and subscriber demographics match the card exactly — name spelling, date of birth, member ID. Two: coverage was active on the date of service, not on the date you are submitting.
Three: the diagnosis supports the procedure. If the ICD-10-CM code doesn't establish why the CPT code was necessary, the claim is a medical necessity denial regardless of how good the care was.
Four: modifiers are present where the code combination requires them, and absent where it doesn't. Modifier 25 on a same-day E/M, modifier 59 or an X-modifier on NCCI edit pairs, component modifiers where the setting calls for them.
Five: place of service, referring provider and authorization number are on the claim where the payer requires them. These are the fields that get skipped because they are usually optional — and denied when they weren't.