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Resolving claim rejections

Resolving claim rejections

When a claim is submitted electronically, an insurance payer can reject it if any errors are detected or if there's invalid information that doesn't match what they have on file. Rejected claims need to be resubmitted with the correct information to be processed. 

Note: For an overview of reviewing a claim rejection, see Checking a claim status: The different phases of an insurance claim

In this guide, we’ll cover:

Important: A rejected claim is not the same as a denied claim. A rejected claim hasn't been accepted by the payer, while a denied claim has been accepted for processing before being deemed not payable. For more information on denied claims, see Handling claim denials.

Understanding what causes claim rejections

When an electronic claim is received by a payer, its information is matched with what the payer has on file. If any information doesn’t align, the claim is rejected from processing. 

Common examples of incorrect information that can cause rejections include: 

Note: For instructions on how to update an ICD code in a client's file, see Using ICD-10 codes for diagnoses.  

If your own billing information was incorrectly entered or isn't up-to-date, it can also result in rejections. Examples of this include: 

Important: Payers typically aren’t able to directly assist with claim rejections. This is because the claims are rejected before being accepted for processing and aren't stored in the payer's system. However, you can contact a payer and confirm that a client’s insurance information is correct and/or if they have your up-to-date billing information on file. Doing this can resolve many claim rejections and confirm your settings and client information are correct so that future claims won’t be rejected. 

See Common primary claim rejections for a list of known rejections and how to resolve them. 

Resubmitting rejected claims

Payers are typically unable to assist with rejected claims, so we recommend reviewing the cause of rejection and locating the missing or invalid information that was submitted.  

Many claim rejections can be resolved by reviewing both the client’s insurance ID card and your billing information. If a claim is rejected, here are some things to review:

  • Is the client's member ID and insurance payer correct?
  • Is their demographic information correct?
  • Is the billing information in boxes 24j, 25, and 33 correct? 

If you're able to determine what caused the rejection, follow the steps below to resubmit the claim. If you're unable to determine the cause of the rejection, see the Common primary claim rejections table below for a list of common rejections. 

To resubmit a claim:

  • Save the Clearinghouse Reference # located at the top of the claim and download the rejected claim
  • Delete the rejected claim 
    • Because backend data gets tied to electronic claims, rejected claims should be deleted and recreated when resubmitting to avoid additional processing issues
  • Make the necessary corrections to the client’s file, appointment details, or your own billing information
  • Recreate the claim so that these changes are applied
  • Submit the claim as an Original in box 22
    • All newly created claims are automatically set as Original, so you can leave this as is. Rejected claims are resubmitted as Original because the payers never properly received the initial claims due to the rejections

Important: Deleting claims is a permanent action. When claims are deleted, all information listed in them is deleted from our database and can't be recovered. To keep this information for your records, we recommend downloading and saving a claim to a client's profile before deleting it. See Uploading a new client file for steps on how you can store this. When deleting a claim, it’s recommended that you save the  clearinghouse reference number and claim number for your records as well.

Common primary claim rejections

We’ve included the most common rejections our customers encounter in the table below. The table is searchable by rejection message, so it’s recommended that you copy from the rejected claim message directly. When copying a rejection, capture only the base cause of the rejection. 

In the sample below, Patient eligibility not found with Payer is the key piece of information:

Once you’ve copied the rejection, use Cmd+F on a Mac or Ctrl+F on a Windows device to search the table and paste the rejection. 

If you don’t see the claim rejection message you’ve received, you can submit a help request so we can investigate further. 

Note: Keep in mind that this table is specifically for primary claim rejections. If you want to see rejection messages for secondary claims, see the Common secondary claim rejections table.

Common secondary claim rejections

The table below lists rejections that are specific to secondary claims. If you don't see the claim rejection you've received, you can submit a help request so we can investigate further. 

Note: For more information on secondary claims, see Filing secondary insurance claims.

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