Quick Explanation
Denial code 98 indicates that the payer has temporarily suspended the patient's insurance benefits while conducting an active investigation. This suspension is typically triggered to resolve Coordination of Benefits (COB) discrepancies, verify primary versus secondary coverage, or investigate potential third-party liability such as a work-related or auto accident. Until the investigation is finalized, claims submitted under this policy will remain unpaid.
Common Causes for 98
Denials with code 98 typically happen for the following specific reasons:
- The payer requires an updated Coordination of Benefits (COB) questionnaire directly from the policyholder to determine correct primary/secondary payer order.
- The diagnosis codes on the claim suggest potential third-party liability (TPL), such as an auto accident or workers' compensation case, requiring investigation.
- The subscriber's policy eligibility is undergoing a routine or targeted fraud, waste, and abuse (FWA) review or audit by the payer.
- Unresolved discrepancies exist regarding the patient's enrollment status, employer group updates, or dependent eligibility.
How to Prevent 98 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Perform robust real-time eligibility (RTE) checks at the time of service to identify active COB or secondary insurance requirements.
- Implement a mandatory patient registration questionnaire that screens for potential work-related or auto accident-related injuries prior to billing.
- Encourage the patient to contact their insurer directly to resolve any pending COB or policy verification issues immediately upon scheduling.
- Establish a proactive workflow to quickly respond to payer requests for medical records or audit questionnaires to minimize investigation delays.
Appeal Letter Template for 98
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: 98 - Benefits suspended - investigation in progress
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code 98: "Benefits suspended - investigation in progress".
We are appealing the denial of this claim, designated under Denial Code 98 (Benefits suspended - investigation in progress), as the medical services rendered were medically necessary and the patient's active coverage has been verified. Under CMS and industry standard Coordination of Benefits (COB) guidelines, the timely adjudication of claims should not be indefinitely delayed when valid coverage is established. We have confirmed with the beneficiary that all primary and secondary payer information is current, and no third-party liability applies to this specific service. Attached, please find the updated COB documentation, the complete medical record, and proof of the patient's active enrollment. We request that you immediately resolve the suspension and process this claim for reimbursement.
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]
Stop Writing Appeals Manually
Clausea can read your medical records and generate custom, evidence-based appeals for denial code 98 in seconds.
Generate Appeal for 98 Now