Documentation that prevents claim rejections: a checklist for doctors

Written by the Netus Health team · October 2026

The insurer never sees the patient; it sees what was written in the file. Every procedure, drug or test that is billed must be justified in the documentation. A large share of rejected claims can therefore be prevented in the consultation room, before the file reaches billing.

Checklist before closing the visit

• The chief complaint, history, examination findings and plan are recorded for this visit.
• The diagnosis justifies every procedure, test and drug ordered in the visit.
• The diagnosis is coded to the highest specificity the file allows, such as laterality, type and stage.
• No 'unspecified' code is used when the more specific information is written in the file.
• Prior approval was obtained before the service when the insurer requires it, and its number is recorded.
• Every billed service is written in the file, and no undocumented service is billed.
• The file is signed and dated by the treating doctor.

The most common rejection reasons

• No prior approval for a service that requires one.
• A diagnosis that does not justify the billed procedure.
• Problems with the patient's eligibility or card validity on the day of the visit.
• Coding errors or unspecified codes.
• A duplicate claim.
• Submitting the claim after the deadline.