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:
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
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:
- Save the Clearinghouse Reference # located at the top of the claim and download the rejected claim
- After downloading the claim, you can store it in the client’s profile in case of timely filing issues
- 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.