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Resolving claim rejections

Resolving claim rejections

Claims are most often rejected due to incorrect or invalid information that doesn’t match what’s on file with the payer. Rejections can come from either the clearinghouse or the insurance payer. A rejection status does not necessarily indicate that the payer has determined that the claim is not payable.

Below, we’ve provided tables where you can find the most common rejection messages, what they mean, and the next steps we recommend taking.

In this guide, we'll cover:

Note: The quickest way to determine the best next steps if you received a claim rejection is to reach out to the payer directly.


Understanding claim rejections

Sometimes what's listed on the claim doesn’t match what the payer has on record for the client, the provider, or the information isn’t in alignment with the payer’s guidelines for electronic claim filing. When this happens, a claim can be rejected with a message that it wasn’t able to be accepted for processing.

When a claim is rejected, it indicates that the claim was:

  • Successfully created in SimplePractice
  • Accepted by our clearinghouse
  • Rejected once sent to the insurance payer for processing

Since a rejected claim wasn’t fully accepted into the payer’s system, many insurance payers won’t have a record of the claim. This means that it’s important to review the message that’s issued by the payer’s system to point you in the right direction on how to resolve the rejected claim. 

Below are the common areas that can lead to a rejected claim. For more information on specific rejection messages, see the Primary claim rejection message table.

Subscriber / Patient / Member

These fields are how the payer identifies that the client listed on the claim has an active policy in their system for the dates of service filed. If a claim is rejected for a reason referencing the Subscriber, Patient, or Member, the next step is to review the client’s member ID card. Review the client’s member ID card to ensure that all information is accurately entered on the claim form and matches what the payer has on file. 

Provider Details

Note: This includes the Billing Provider NPI, Rendering Provider NPI, Tax ID, and Taxonomy Codes.

Similar to a Subscriber rejection, this indicates that the insurance payer can’t locate the provider, based on the information listed on the claim. This can happen suddenly if the payer has updated their database, or if the NPI on file has become inactive. With this rejection message, you'll first want to follow up with the payer directly to verify that all information matches what they have on file and is active. You can then review your SimplePractice settings to ensure that the correct information is populating onto your claims. If there's a different NPI in Box 24 and Box 33, you'll also want to ensure that these are linked in the payer’s system.

CPT Codes / Modifiers / Diagnosis Codes

Some insurance payers will reject a claim if an unauthorized CPT code or modifier combination is used, based on their claim filing guidelines. These guidelines are established by each insurance payer individually, so you'll want to follow up with the payer directly to check that the codes included on the claim form are within their restrictions. 

Next steps

Once you’ve determined the rejection reason, you can:

  • Update the appropriate setting in your SimplePractice account to ensure that the correct information populates going forward
  • Download a copy of the original claim
  • Make note of both the Clearinghouse Reference Number, and the Payer Claim Number if it's available
    • This will ensure both are easily accessible in case there's an issue with timely filing
  • Delete the previously rejected claim and recreate it

Note: If a claim is missing information, our clearinghouse may scrub the claim to keep it from being rejected unnecessarily. For more information on how scrub errors are handled in SimplePractice, see: Scrub errors when trying to file insurance claims.

The rejection messages that are issued from the insurance payers don't always give a clear place to start, or may state something vague such as Missing or Invalid Information. If this is the case, you can reach out to our support team and we’ll investigate further.


Primary claim rejection message table

Please note that the table below is searchable only by rejection message, so make sure to carefully include the exact rejection message in your search. Additionally, the table contains only the most common primary claim rejection messages we see. If you don't see the claim rejection message you've received, we recommend reaching out directly to the payer for guidance.

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 Secondary claim rejection message table section. 

Rejection Message Rejection Clarification Action Items

 


Secondary claim rejection message table

The table below shows the exact rejection message for secondary claims. Please keep in mind that these are only the most common secondary claim rejection messages we see. If you don't see the claim rejection message you've received, we recommend reaching out directly to the payer for guidance.

Note: This table is specifically for secondary claim rejections. If you want to see rejection messages for primary claims, see the Primary claim rejection message table section. 

Rejection Message

Rejection Clarification

Action Items

Acknowledgement/Returned as unprocessable claim-The claim/encounter has been rejected and has not been entered into the adjudication system. (A3) Missing or invalid information. OTHER SUBSCRIBER ID (OTHER SUBSCRIBER NAME LOOP, IDENTIFICATION CODE) CAN CONTAIN ONLY ALPHANUMERIC CHARACTERS. PUNCTUATION AND OTHER SPECIAL CHARACTERS ARE NOT ALLOWED. (21) This means that Box 9a1 or 9a3 have a character that the payer is rejecting, most likely a dash (“-”)

In order to correct this, you’ll need to:

  1. Delete the secondary claim
  2. Go back to the primary claim and click Edit to Resubmit
  3. Delete any special characters from the Member ID in Box 1a and/or Group ID in Box 11.
  4. Click Save (not “Submit”), then Download
  5. Recreate Secondary Claim

There was an error retrieving the information. 

Most likely, the claim has been edited multiple times and caused the claim to be disconnected from the code Delete and recreate the secondary claim to submit

The claim's service line 2: Diagnosis pointer is required

Sum of charge amount in service lines should be equal to total charge amount for the claim

The claim has service lines that were manually removed or added

Delete and recreate secondary claims without manually adjusting the service lines.

If you need to add extra dates of services, you'll want to schedule the appointment on the calendar and create a separate primary claim from the client's billing. For example, if there was only 1 date of service on the primary claim, the secondary claim needs to have 1 date of service.

Missing or invalid information. R CLAIM LEVEL COB INFORMATION INVALID; CLAIM TOTAL CHARGE MINUS CLAIM ADJUSTMENT AMOUNTS MUST EQUAL PAYER PAID AMOUNT WHEN LINE LEVEL ADJUDICATION IS NOT PRESENT FOR THAT PAYER

Incorrect information in Box 8 and/or 24

If you have received a Payment Report (ERA) for the primary claim, then please delete and recreate the claim without any further adjustments.

If you have not received a Payment Report (ERA), please refer to this Help Center guide for detailed instructions on how to submit correct information in Box 8 and 24.

The claim/encounter has been rejected and has not been entered into the adjudication system. (A3) claim[service_lines][0][cob][0][procedure_code] has data errors. Too many components in claim[service_lines][0][cob][0][procedure_code] (21)

Incorrect or missing information in Box 24 1a, 1b, or 1c.

Review through Box 24 1a, 1b, or 1c to ensure there is information present.


Things to consider

  • A rejected claim isn’t the same as a denied claim
    • A denied claim has been fully processed by the insurance payer, while a rejected claim hasn’t been processed and never entered the payer’s system
    • Payers aren’t often able to locate a rejected claim, because the rejection was issued before the claim was fully processed in their system
  • Based on the rejection message, gather additional information from the client such as:
    • A member ID card
    • Updated information
    • A coordination of benefits
      • This may be necessary to understand the rejection message
  • When the rejection message is related to the Billing Provider, Rendering Provider, or Tax ID, the first step is to verify the provider credentials with the payer
  • If you’ve called the payer to discuss a claim rejection, please take note of the following details from this call:
    • Name of the representative
    • Number you called
    • Call reference number

Note: If you require additional assistance, you can contact our support team. Please make sure to have the information above prepared when reaching out to us.


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