User Guide — How To Prevent Common Denials

athenaCollector

A payer may deny a claim even when athenaOne receives a "Member is eligible" response from the payer.

  • Eligibility information must be applied correctly to a patient encounter to effectively prevent a denial.
  • Benefit coverage depends on the type of service, provider network status, and patient's classification on the policy.
  • Member is eligible indicates that the patient is on file at the payer with active coverage, but it does not guarantee that a given claim will be paid.

Refer to the list of common kick codes and prevention of common denials.

 

Kick code meaning: The DOB, address, and/or other demographic of the insured is either missing or invalid.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

Kick code meaning: No authorization on file for this service, or authorization information is invalid.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

Kick code meaning: Dependent is not covered on this plan or there is a problem with dependent's coverage
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies as well as the Benefit Detail section for any limitations (for example, dependent age) that may apply.

 

Kick code meaning: Insured group number is missing or invalid for this payer.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

Kick code meaning: Incorrect insurance ID number: payer has indicated that the insurance ID on claim form is incorrect.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

Kick code meaning: Patient name contains invalid data or is missing data, or a space before the first letter.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

The insured's name is either missing or invalid.
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

This service is not a covered benefit, and the patient cannot be billed for this service.
  • Status: MGRHOLD
  • Action: See the Benefit Detail section to see if the patient has coverage for this type of service.

 

Kick code meaning: No PCP on file for this claim
  • Status: HOLD
  • Action: See the Benefit Detail section to see if the patient's PCP is correct.

 

Kick code meaning: Invalid information in patient's address  
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.

 

Kick code meaning: Referring provider ID and/or name is missing/not valid
  • Status: HOLD
  • Action: See the Benefit Detail section to see if the patient's PCP is correct.

 

Kick code meaning: Referral required. Insurer does not have a referral on file for this claim or has incorrect information.
  • Status: HOLD
  • Action: See the Benefit Detail to verify if a referral is required for the claim's type of service.

 

Kick code meaning: Patient is a managed care plan member (HMO, IPA, PHO) or enrolled in another specialized program.
  • Status: HOLD
  • Action: See the Benefit Detail for type of plan information as well as Other Payer information.

 

Kick code meaning: Invalid relationship to insured code or information
  • Status: HOLD
  • Action: Check the Payer Demographic Information section for any discrepancies.