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Medical Billing: Causes of Claim Denial under the 5010 Platform

As a medical billing professional, you may find yourself faced with claim denial under the 5010 platform. Every step that delays the claim also delays the payment. Possible causes of rejections or denials under 5010 include the following:

  • Failure to bill under the NPI number: The old platform, 4010, allowed claims to be billed under the Tax ID number.

  • Using a P.O. box or an abbreviated zip code for the provider’s address. The 5010 platform requires a physical address to be provided as a place of service; a P.O. box is not acceptable. In addition, the zip code must be the full nine digits.

  • Exceeding the number of diagnosis codes a procedure can be linked to: Each procedure can be linked to a maximum of four diagnosis codes if you submit it on an HCFA.

  • Not using verbal code descriptions when needed: Unlisted or unspecifiedprocedural codes must have a verbal code description.

  • Not including a secondary payer indicator when needed: If Medicare is the primary payer and a secondary payer or supplement plan exists, the secondary payer indicator must be on the claim.

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