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. Below, we'll cover:

• Understanding what causes claim rejections
• Resubmitting rejected claims

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:

• Insurance information
  • Incorrect member ID
  • Incorrect payer ID
• Demographic information
  • Incorrect date of birth
  • Misspelled name
  • Incorrect address
• Diagnosis codes/billing information
  • Invalid or outdated ICD code
  • Invalid CPT code
  • Incorrect or missing modifier

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:

• Using an incorrect taxonomy code
  • For steps on how to identify and update your taxonomy code if necessary, see Identifying your taxonomy code for claims
• Using a billing address, TIN, rendering NPI, and/or billing NPI not on file with the payer
  • For more information on setting up your insurance billing information, see Entering your billing information  

Important: Payers typically aren’t able to directly assist with claim rejections. This is because 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.

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:

1. Click Create Corrected Claim

2. Confirm which appointments should be included on the corrected claim, then click Continue

3. Confirm that you’d like to archive the original claim

4. Make any necessary edits based on what needs to be corrected
5. Leave the claim as an Original in box 22
6. Return to the top of the claim and click Save
7. Submit the corrected claim

As you archive and resubmit claims, you can review their history for details such as submission timeline and past clearinghouse reference numbers.