Common ABA Denial Codes: Top 10 Insurance Rejections

Your Guide to Cleaner Claims for Large ABA Group Practices when it comes to Common ABA Denial Codes

ABA billing is complicated enough, and when you’re managing a large group practice with multiple rendering providers, denials can pile up quickly. The good news? Most denials can be prevented or corrected with the right strategy.

We specialize in helping ABA providers identify denial patterns, resubmit correctly, and recover reimbursement faster.

Here’s a comprehensive look at the top 10 most common ABA denial codes, what causes them, and what to do when it happens.

Top 🔟 Common ABA Claim Denials and How to Fix Them

1. Rendering Provider Not Active on Date of Service

Reason for Denial: The rendering provider was either not enrolled, inactive, or not credentialed with the payer on the DOS.
Resolution Tips:

Confirm provider credentials and effective dates in ePREP (Maryland) or CAQH.
Always check that the provider is active on the exact date of service.
Resubmit only after verifying that the provider status is active.

2. Prior Authorization Required

Reason for Denial: Services were rendered without an approved authorization.
Resolution Tips:

Call the insurance company to verify if retro-authorizations are allowed.
Submit the authorization number in the appropriate box on the claim form (Box 23 for CMS-1500).
Resubmit the same claim as corrected with the authorization reference.

3. Missing or Incorrect Modifiers

Reason for Denial: Required CPT modifiers (e.g., GT for telehealth, U2 for child present) were not included or were incorrect.
Resolution Tips:

Cross-check CPT codes with payer modifier guidelines.
Add the correct modifier(s) and resubmit as a corrected claim.
For paper claims, write “CORRECTED CLAIM” at the top of the CMS-1500 and use resubmission code 7 in Box 22 with the original claim reference number.

4. Provider Not Credentialed with Insurance

Reason for Denial: The provider is not in-network or credentialed.
Resolution Tips:

Verify credentialing status through the payer or ePREP.
If credentialing is pending, ask the payer if claims can be backdated once approved.
Don’t resubmit until credentialing is confirmed unless the payer allows retroactive billing.

5. Maximum Allowed Amount Exceeded

Reason for Denial: The claim exceeds the plan’s daily or monthly unit/hours limit.
Resolution Tips:

Review the authorization and fee schedule for allowed units.
Contact the insurance for a unit extension or submit a services addendum.
If approved, resubmit with medical necessity documentation.

6. Primary Insurance Paid Up to Allowed Amount

Reason for Denial: When billing secondary, the primary payer covered the full allowed amount, and the secondary denies.
Resolution Tips:

Submit the Explanation of Benefits (EOB) from the primary payer.
Use correct coordination of benefit codes (COB).
Resubmit as a new claim with the primary EOB attached if it wasn’t submitted initially.

7. Service Not Covered by the Plan

Reason for Denial: ABA therapy or specific CPT codes may not be covered.
Resolution Tips:

Verify the plan’s coverage and exclusions before the DOS.
Submit a Letter of Medical Necessity with supporting clinical documentation.
If denied again, appeal with supporting documentation—don’t just resubmit.

8. Provider NPI Not Recognized

Reason for Denial: The NPI listed doesn’t match provider records or isn’t registered.
Resolution Tips:

Double-check the NPI number and taxonomy with NPPES.
Ensure the provider NPI is enrolled with the payer and linked correctly.
Resubmit as corrected using the valid NPI.

9. Duplicate Claim Submission (Denial Code 94)

Reason for Denial: The same claim was submitted more than once without correction.
Resolution Tips:

Don’t simply resubmit the claim.
If a correction is needed, mark it as “corrected” with resubmission code 7 and list the original claim number.
UB-04: Use bill type ending in 7.
Avoid “re-drops” unless the claim is completely denied.

10. Incomplete or Incorrect Patient Information

Reason for Denial: Mismatched names, DOB, ID numbers, or gender.
Resolution Tips:

Verify patient details with the insurance.
Submit as corrected claim after fixing patient info.
Be sure all demographic fields are consistent with the policy.

📄 How to Resubmit a Denied Claim

When resubmitting a claim, follow these best practices:

➤ When to Resubmit:

If the claim was denied but not paid, submit a brand-new claim.
If the claim was paid but paid incorrectly, submit a corrected claim.

➤ How to Resubmit:

CMS-1500:

Write “Corrected Claim” at the top of the form.
Enter resubmission code 7 in Box 22.
Add the original claim number in the adjacent field.
Attach necessary documentation (e.g., auth, EOB, modifiers).

UB-04:

Change the bill type to end in “7” to indicate a correction.
Include original claim number and updated info.

Electronic Submissions:

Use your clearinghouse’s option for corrected claims.
Add frequency code 7 and original claim control number (ICN).
Attach supporting documents if your software allows (e.g., EOBs, auths).

📞 When to Call the Insurance Company For Common ABA Denial Codes

Contact the payer directly if:

The denial reason is unclear or lacks a denial code.
You’ve submitted multiple times with no response.
You’re requesting a retro authorization or unit extension.
The portal shows the claim paid but the check/EFT hasn’t posted.

Pro Tip: Always ask for a reference number, rep’s name, and instructions for resubmission or appeal.

✅ Final Tips for Common ABA Denial Codes & Claim Resubmissions

Keep a claim tracker for denied and corrected claims.
Document every payer call and upload to the patient file.
Make sure modifiers, POS, NPIs, and patient info match across the claim and documentation.
Always resubmit within the timely filing limit—typically 90–180 days.

We Can Handle Your ABA Denials

We don’t just submit claims—we rescue them. Whether you’re struggling with high-volume denials or need a clean-up of aged claims, our team is trained to:

Analyze denial trends
Submit corrected claims
Process appeals efficiently
Ensure clean billing practices moving forward

See: Denial Code 286: A Comprehensive Guide for Healthcare Providers

We help with Verifying Provider Status and Managing Denials

We are not just billers—we are your extended team. From verifying a provider’s status to handling complex denials and appeals, we ensure your claims are clean, compliant, and paid faster.

If your organization needs help with:

✅ Medical billing services
✅ Verifying provider credentials and enrollment
✅ Denial management and appeals
✅ Credentialing or pre-claim checks

📞 Call us today at 844-TAYLOR-9 (844-829-5679)
🌐 Visit: www.taylorprimesolutions.com
📧 Message us here

Let us take the billing burden off your shoulders so you can focus on care, not claims.