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Resolving claim rejections

Resolving claim rejections

When a claim is submitted electronically, it can be rejected if any errors are detected or if there's any incorrect or invalid information that doesn't match what's on file with the payer. This means the claim needs to be submitted with the correct information before it can be processed. 

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 and then is deemed not payable. For more information on denied claims and what to do, see: What do I do if my claim is denied? 


What causes a claim to be rejected?

Once a claim is submitted electronically, the information on that claim is matched with what the payer has on file. If any information doesn’t align, the claim is rejected and not accepted for 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/billing information
    • Invalid or outdated ICD code
    • Invalid CPT code
    • Incorrect modifier or lack of a required 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: 

Important: Payers typically aren’t able to directly assist with claim rejections, since the claims are rejected for processing and aren’t stored in their system. However, you’re always able to 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 ensure your settings and client information are updated so that future claims won’t be rejected. 

There are other possible rejections that aren’t as straightforward. See Common primary claim rejections for a list of known rejections and how to resolve them.  


What do I do when a claim is rejected?

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 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 these steps to resubmit the claim: 

  • Save the clearinghouse reference number located at the top of the claim and download the rejected claim.
    • This is so you can store the rejected claim's information. Storing a rejected claim’s information can be beneficial in case timely filing issues arise, as well as allowing our team to assist with additional claim troubleshooting.
  • Delete the rejected claim. 
    • When a claim is submitted, backend data gets tied to that claim, even if it's rejected. If a claim needs to be resubmitted, we recommend deleting and recreating it to reduce the likelihood of 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 populate it.
  • Submit the claim as an Original in Box 22.
    • All newly created claims are automatically set as Original, so leave this as is. Claims are submitted as Original because the payers never properly received them due to the rejection.

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. 

If the rejection you're encountering isn't in the table, you can reach out to our insurance team and we'll investigate further with our clearinghouse.


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:

rejectioncause.simplepractice.claims.png

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, reach out to our insurance team and we’ll investigate further with our clearinghouse. 

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 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, reach out to our insurance team and we’ll investigate further with our clearinghouse. 

 

 


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