What is the recommended action when a CMS-1500 claim is denied as not covered?

• A. Ignore the denial and wait for payer to reconsider.
• B. Change the diagnosis code to a higher level without justification.
• C. Review documentation and codes for medical necessity, verify coverage, correct coding errors, and resubmit with updated information.
• D. Request a different payer.

Answer: (C)

When a CMS-1500 claim is denied as not covered, the best course is to reexamine the submission for medical necessity and coverage, fix any coding or documentation gaps, and resubmit with accurate, policy-aligned information. Start by checking the payer’s medical policy and the patient’s benefits to confirm whether the service should be covered. Review the clinical documentation to ensure it clearly supports medical necessity for the CPT/HCPCS codes billed and that the ICD-10-CM diagnosis justifies those codes. Look for and correct any coding errors, such as mismatches between diagnosis and procedure codes, missing modifiers, or incorrect place of service. If needed, gather additional supporting documentation (progress notes, test results, physician rationale) and align the claim to the payer’s requirements before resubmitting. If appropriate, follow the payer’s appeal process to dispute the denial.

Ignoring the denial, altering a diagnosis code to a higher level without justification, or merely asking for a different payer would not address the underlying issue and could lead to further problems or noncompliance.