What is a reason that a payer would deny a claim?

A payer could deny a claim if an edit rule was violated because edit rules are established guidelines that dictate what is a valid and acceptable claim submission. These rules often include protocols related to coding accuracy, services rendered, and patient eligibility. For instance, if a claim submission does not comply with these criteria—such as using an incompatible code or failing to provide necessary documentation—the payer may automatically reject the claim.

The other options do not typically lead to outright denial of a claim in the same manner. For example, using a new CPT code may require additional review but does not automatically result in denial; as long as the code is valid and accurate for the services provided, it can be accepted. A patient’s inability to pay the claim refers more to patient responsibility rather than an issue with insurance processing, and thus does not influence the payer's decision directly. Lastly, if only a percentage of the claim is to be paid, this reflects the co-insurance structure of the policy rather than a denial.