Charge Exceeds Fee Schedule

Common Causes for 45

Denials with code 45 typically happen for the following specific reasons:

• Provider billed a fee higher than the payer’s contracted rate for the specific CPT/HCPCS code.
• Fee schedule was not updated to reflect recent payer contract changes or rate updates.
• Incorrect modifier was used, resulting in a higher billed amount than allowed by payer policy.
• Duplicate claim was submitted for the same service, triggering a reduced payment or denial.
• Provider did not verify patient eligibility or benefits, leading to billing at out-of-network or non-contracted rates.

How to Prevent 45 Denials

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

• Regularly update internal fee schedules to match current payer contracts and fee arrangements.
• Verify patient eligibility and benefits prior to service, confirming in-network status and allowed rates.
• Double-check CPT/HCPCS codes and modifiers for accuracy before claim submission.
• Implement claim scrubbing software to flag charges exceeding payer fee schedules.
• Audit claims for duplicate submissions and ensure each service is billed only once.

Appeal Letter Template for 45

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: 45 - Charge Exceeds Fee Schedule

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code 45: "Charge Exceeds Fee Schedule".

The submitted claim for [CPT/HCPCS code] was billed in accordance with the provider’s contracted fee schedule and reflects the actual cost of delivering medically necessary services as documented in the patient’s clinical record. The payer’s allowed amount appears to be below the contracted rate for this service, as evidenced by the most recent contract addendum and fee schedule provided by the payer. We request a review of the payment adjustment and reimbursement at the contracted rate, as the service was rendered within the terms of the agreement and in compliance with payer policy. Supporting documentation, including the contract, fee schedule, and clinical notes, is available upon request.

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]