Therapy Denial Code Reference

The payer required prior authorization or precertification before the service, and none was on file when the claim arrived. This is one of the most common denials in outpatient therapy, especially since UnitedHealthcare added prior auth requirements for outpatient SLP under Medicare Advantage effective September 1, 2024.

Watch out: Verify auth requirements at intake for every payer and plan type, not just known high-auth payers. Confirm auth covers the correct CPT codes (for example, 97153 and 97155 bill separately for ABA and each may require its own auth). Log the auth number and expiration before the first date of service. Relay flags any scheduled visit that does not have a verified auth on file before the claim is generated.

The payer determined the service is not covered under this patient's benefit plan. In pediatric therapy, this appears most often when a plan excludes a specific discipline (some plans cover PT and OT but exclude ABA, for example) or when the place of service or patient age falls outside coverage parameters.

Watch out: Verify benefit coverage for each discipline at intake, not just insurance eligibility. Eligibility confirmation tells you the plan is active; it does not tell you the plan covers the service. Pull a benefits breakdown by CPT code or service category before scheduling. If a plan excludes a discipline, document the conversation with the family and provide a good-faith cost estimate before treatment begins. Relay cross-references the billed CPT against the verified benefits on file and flags exclusions before the first claim is submitted.

The payer reviewed the claim and concluded the service did not meet its medical necessity criteria. In pediatric therapy, this most often happens when documentation does not clearly connect the CPT billed (such as 97530 or 92507) to a covered diagnosis or when the frequency appears unsupported by the clinical record.

Watch out: Documentation needs to justify the visit, not just describe it. The treatment note should reference the patient's functional deficits, the specific goal being targeted, and measurable progress or lack thereof explaining continued need. For ABA, connect 97153 units billed to the active 97151 assessment. For SLP, tie 92507 treatment to the 92523 eval findings. Relay cross-checks billed codes against diagnosis codes and flags mismatches before the claim goes out.

The payer's utilization review determined that the number of units, visits, or services billed exceeds what it considers appropriate for the diagnosis and plan of care. This shows up most in high-unit CPT codes like 97153 (ABA direct treatment) when units spike without a corresponding update to the treatment authorization.

Watch out: Stay current on each payer's visit and unit limits by CPT code and diagnosis. When treatment intensity increases, update the authorization before billing the higher volume. For ABA, ensure that 97153 units billed do not exceed the authorized hours and that 97155 protocol modification notes are documented for each session involving the supervising BCBA. Relay tracks authorized units against billed units in real time and flags claims where billed volume is approaching or exceeding the authorized ceiling.

The claim is missing a field or has an incomplete entry the payer needs to process it. This can be a missing referral number, an incomplete NPI, a modifier that was dropped, or an unlisted place of service code. The payer is not saying the service is wrong; it is saying it cannot evaluate the claim as submitted.

Watch out: Run a pre-submission scrub on every claim. Confirm that therapy modifiers are present where required: GN for SLP, GO for OT, GP for PT. Verify that the rendering provider NPI matches the credentialed NPI on file with the payer. For claims requiring a referral, confirm the referral number is populated and has not expired. Relay's pre-submission check catches missing modifier and NPI mismatches before the claim leaves your system.

The claim arrived after the payer's filing deadline. Deadlines vary: some payers allow 90 days from the date of service, others allow up to a year. Once the window closes, the payer will not pay regardless of whether the service was covered and medically necessary.

Watch out: Track filing deadlines by payer and flag any claim that has not been submitted within two-thirds of the deadline. Secondary claims have their own timely filing clocks that start when the primary EOB is issued, not the date of service. Do not let unworked claims age silently. Relay surfaces claims approaching their filing window so nothing slips through on a busy week.

This is patient responsibility, not a true denial, but it frequently generates confusion and collections delays. The payer applied some or all of the allowed amount to the patient's unmet deductible. The claim processed correctly; the patient owes the money, not the payer.

Watch out: Collect real-time eligibility at every visit, not just at intake. Deductibles reset on January 1 for most commercial plans, which means the first quarter of every year brings a wave of PR-1 balances from families who were fully covered in December. Brief front-desk staff on this pattern before January. Relay pulls live eligibility checks before each appointment and surfaces remaining deductible balances so your team can have the financial conversation before the visit, not after.