Expenses Prior to Coverage

Common Causes for 26

Denials with code 26 typically happen for the following specific reasons:

• Patient received services during a waiting period before their insurance policy officially began.
• Services were provided before the effective date of a new insurance plan, such as after switching insurers or enrolling for the first time.
• Billing staff failed to verify the patient's insurance effective date before scheduling or rendering services.
• Patient was covered under a previous plan that lapsed, and new coverage had not yet started on the date of service.
• Employer-sponsored coverage had a delayed start date, and services were provided before that date.

How to Prevent 26 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Verify the patient's insurance effective date at every encounter using real-time eligibility tools.
• Document and confirm the insurance start date in the patient registration system and flag any services scheduled before coverage begins.
• Train front desk and scheduling staff to check coverage effective dates before confirming appointments.
• Implement a pre-authorization or pre-service insurance validation workflow for all non-emergent services.
• Use automated eligibility checks integrated into the EHR or billing system to flag potential coverage gaps.

Appeal Letter Template for 26

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: 26 - Expenses Prior to Coverage

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 26: "Expenses Prior to Coverage".

The claim should be reconsidered as payable because the services rendered were medically necessary and provided during a period when the patient was actively enrolled and eligible for coverage, as evidenced by the insurance policy documents and enrollment records. The effective date of coverage may have been misinterpreted or administratively delayed, but the patient met all eligibility requirements and premiums were paid in full prior to the date of service. Furthermore, the services were not elective or non-urgent, and delaying care would have posed a clinical risk to the patient. Therefore, payment should be granted in accordance with the insurer's contractual obligations and the principle of timely access to medically necessary care.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]