Denial categories
BCBS Denial Categories by Root Cause
Group denial codes by root cause so providers can work them faster: prior authorization, timely filing, medical necessity, COB, eligibility, documentation, coding and payment disputes.
Prior authorization denialsBCBS prior authorization denial workflows for absent, exceeded, expired, or mismatched authorization and referral issues.Timely filing denialsBCBS timely filing denial workflows, evidence checklists, accepted submission proof, and CO-29 appeal support.Medical necessity denialsBCBS medical necessity appeal workflows for policy criteria, clinical records, and provider letters.Coordination of benefits denialsBCBS COB denial workflows for primary EOBs, Medicare crossover, payer order, and member COB updates.Eligibility and member ID denialsBCBS eligibility denial workflows for member ID, coverage dates, dependent status, and wrong-payer claim routing.Documentation and attachment denialsBCBS record request and attachment-required denial workflows with proof of submission and document packet indexing.Coding, modifier and bundling denialsBCBS coding denial workflows for modifiers, bundled services, revenue code edits, and incompatible procedures.Payment disputes and contractual adjustmentsBCBS payment dispute workflows for CO-45, underpayments, contractual adjustments, and fee schedule issues.Appeal process and deadline denialsBCBS appeal process workflows for missed deadlines, procedural denials, and original decision maintained notices.Provider enrollment and NPI denialsBCBS provider eligibility workflows for NPI, taxonomy, provider specialty, billing provider, and roster issues.