Claim denied as patient cannot be identified

Patient Cannot Be Identified as Our Insured (Denial Code 31) – Causes, Fix & Call Flow

Introduction
In medical billing, one of the common denials is Denial Code 31: Patient cannot be identified as our insured.
This denial usually happens when the payer cannot match the patient details with their records. It can delay payments and increase AR days if not handled correctly.

This blog explains:
• What this denial means
• Why it happens
• Exact call flow to resolve it
• Important actions to prevent repeat denials

What is Denial Code 31: Patient Cannot Be Identified?
Denial Code 31 occurs when the insurance company is unable to identify the patient as their member.

This typically happens because the billed claim has:
• Incorrect Patient Name
• Incorrect Date of Birth (DOB)
• Incorrect Gender
• Incorrect or missing Member/Policy ID

Why Does This Denial Occur?
The payer system matches the claim with member eligibility records.

If there is even a small mismatch (example: name spelling issue or DOB digit error), the payer may deny the claim with “patient cannot be identified.”

Most common reasons:

1. Patient name mismatch (first/last swapped, spelling errors)
2. Wrong DOB or Gender
3. Wrong Member ID / Policy number
4. Missing prefixes (common with BCBS plans)
5. Medicare ID mismatch (HIC/MBI issues)

On-Call Scenario / Call Flow to Resolve Denial 31

Step 1: Ask the Rep to Search the Patient
Start with:

“Could you please search the patient using Name, DOB, or Social Security Number?”

✅ If rep finds the patient → go to Step 2
❌ If rep cannot find the patient → go to Step 8

Step 2: Ask for Correct Policy ID

If the rep found the patient, ask:

“May I have the correct policy ID / member ID?”

Step 3: Check Claim Availability Using Correct Member ID

Ask:

“Can you check if the claim is available for the Date of Service (DOS) under the correct member ID?”

If claim is found:
➡️ Follow AR scenario based on claim status (paid/denied/pending).

If claim is NOT found:
➡️ Proceed to Step 4.

Step 4: Ask Policy Effective & Term Date

Ask:

“May I have the effective date and termed date of the policy?”

Now check:

✅ Does DOS fall within effective and termination period?

• If NO → go to Step 8
• If YES → go to Step 5

Step 5: Ask for Timely Filing Limit (TFL)

Ask:

“May I know the timely filing limit (TFL)?”

Now check:

✅ Is DOS within the timely filing limit?

• If YES → go to Step 6
• If NO → go to Step 7

Step 6: Resubmit Claim (DOS Within TFL)

If DOS is within TFL and patient policy is active:

Ask for:
• Claim mailing address
• Payer ID
• Fax number (if applicable)

Then:

✅ Resubmit claim with corrected member info.

Step 7: DOS Crossed TFL – Ask If Claim Can Be Sent with POTF

If DOS is beyond TFL:

Ask:

“Can we fax or mail the claim along with Proof of Timely Filing (POTF)?”

• If rep says YES:
o Collect fax number / mailing address
o Fax/mail claim + POTF

• If rep says NO:
o Resubmit claim anyway
o Once TFL denial received, send appeal with POTF (as per client process)

Step 8: Rep Unable to Find Patient – Call Reference Number

If rep cannot locate the patient / policy:

Ask:

“May I get the call reference number?”

Then take internal action:

✅ Claim may be released to patient if no other insurance active.

Important Notes & Actions (Must Follow)

Here are critical best practices while working this denial:

1) Verify Insurance Portal Before Patient Responsibility

Before releasing claim to patient, check payer portal (if access available) to confirm member info.

2) Always Check Previous DOS Payments

If previous DOS was paid by another payer:
• verify eligibility for that payer on current DOS
• resubmit to correct payer if policy active

3) If Patient Found But Claim Missing

If policy active + DOS within TFL:
✅ resubmit claim

If policy inactive on DOS:
✅ release claim to patient (if no other insurance)

4) If DOS Crossed TFL

• If POTF available and payer accepts fax/mail → send claim with POTF
• If POTF available but payer doesn’t accept → resubmit, wait for denial, then appeal with POTF
• If no POTF and billed after TFL → write off claim (based on client instructions)

Medicare Special Tips (Very Important)

For Medicare, correct details matter heavily.

• Medicare ID format changed from HIC to MBI
• Both are 11 characters
• MBI is alpha-numeric

If denial occurs:

• Search Medicare portal using MBI + variations of patient name:
o swap first/last names
o try suffixes like Jr, Sr, I, II, III, IV

✅ Important: Never bill Medicare ID denial claim to supplementary plan first — it will also deny due to primary denial.

BCBS Policy Prefix Tip (High Impact)

Many BCBS member IDs require an alpha prefix (3 letters).

If claim is submitted without prefix:
➡️ Denial = Patient not identified

If SSN is available:

• Try searching member using Availity with state-based prefix + SSN

Example prefixes:
• NM state: YIF / XIF + SSN
• MI state: XYL + SSN

(Not 100% guaranteed, but works in some cases.)

Conclusion

Denial Code 31: Patient cannot be identified is mostly caused by demographic or member ID mismatch.

The fastest resolution is:

1. search patient by Name/DOB/SSN
2. confirm correct policy ID
3. check claim status
4. validate eligibility dates + TFL
5. resubmit or send claim with POTF

Following this workflow reduces rework and improves claim payment turnaround.