AR Scenarios in Medical Billing​

In medical billing, AR (Accounts Receivable) scenarios refer to the different situations billing teams face when following up with payers on outstanding claims. These scenarios arise when claims are delayed, denied, or left unpaid, and they require specialized handling to ensure maximum reimbursement.

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Claim Statuses

  • No Claim on File

  • Claim in Process

  • Claim is Approved to Pay

  • Claim Paid

  • Claim Paid & Applied Towards Offset

  • Claim Paid to Patient

  • Claim Applied Towards Deductible

Claim Denial Reasons

  • Claim denied – patient cannot be identified

  • Claim denied – Coverage Terminated

  • Claim denied – The time limit for filing has expired

  • Claim denied – Authorization absent or missing

  • Claim denied – referral is absent or missing

  • Claim denied – maximum benefit exhausted/reached

  • Claim denied – Non covered charges

  • Claim denied – non covered charges as provider is out of network

  • Claim denied – additional information requested from patient

  • Claim denied – Aadditional information requested from provider

  • Claim denied – medical records requested

  • Claim denied – Duplicate

  • Claim denied – patient enrolled in hospice

  • Claim denied – Procedure code inconsistent with the modifier used

  • Claim denied for invalid modifier on date of service

  • Claim denied – Diagnosis code is inconsistent with the procedure

  • Claim denied – diagnosis code is invalid for date of service

  • Claim denied – Procedure code was invalid on the date of service

  • Claim denied – referring provider is not eligible to refer the service billed

  • Claim denied for primary EOB

  • Claim denied – Other payer is primary

  • Claim denied – Secondary payment cannot be considered without the identity of or payment information from the primary payer

  • Claim denied – claim not covered by this payer

  • Claim denied – patient covered under capitation or managed care plan

  • Claim denied for invalid place of service

  • Claim denied – primary paid more than secondary allowed amount

  • Claim denied – Medically not necessity

  • Claim denied – This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier

  • Claim denied – This injury/illness is covered by the liability carrier

  • Claim denied – This injury/illness is the liability of the no-fault carrier/Auto insurance

  • Claim denied – Bundle/Inclusive

  • Claim denied – Globally inclusive to Surgery

  • Claim denied – procedure combination is not compatible with another procedure

  • Claim denied – procedure code is not paid separately

  • Claim denied – rendering provider is not eligible to perform the service billed

  • Claim denied – the procedure code is inconsistent with provider type/specialty

  • Claim denied – routine services not covered

  • Claim denied – This provider was not certified/eligible to be paid for this procedure/service on this date of service

  • Claim denied – pre-existing condition not covered

  • Claim denied – Procedure code is inconsistent with patient’s gender

  • Claim denied – Procedure code is inconsistent with patient’s age

  • Claim denied – Diagnosis code is inconsistent with patient’s gender

  • Claim denied – diagnosis code is inconsistent with patient’s age

  • Claim denied for invalid or missing NDC Code

  • Claim denied for invalid or missing CLIA Number

  • Claim denied for New patient/Established patient criteria not met

  • Claim denied – Prior processing information appears incorrect

  • Claim denied – CPT has reached the maximum allowance for a specific time period

  • Claim denied – the date of death precedes the date of service

  • Claim denied – Procedure/treatment/drug is deemed experimental/investigational by the payer

  • Claim denied – Revenue code and Procedure code do not match

  • Claim denied – Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement

  • Claim denied – Payer deems the information submitted does not support this level of service

  • Claim denied – it is already paid to another provider