REJECTIONS

 A rejection claim is a claim declined by insurance/clearing

house/PMS to transmit or to accept for further processing. Claims
that do not meet the specific data requirements or the basic
format necessary will be rejected. Insurance/Clearing house/PMS
might reject a claim because of various reason incorrect patient
demo, insurance information, Missing/invalid provider information,
missing or invalid other insurance information etc.
 REJECTIONS
 Billing validations – The validations that the claim goes through
in Billing software when the claim is prepared to be sent to the
payer. It is also called as front end rejections.
 Clearinghouse validations – The validations that the claim goes
through at the clearinghouse when the claim is received by the
clearinghouse. This may include validations for any payer
specific requirements.
 Payer validations – The validations that the claim goes through
at the Payer when the claim is received by the payer.
 REJECTIONS
Difference between claim rejection and denial?

Rejection Denial
 A claim will be rejected by  A claim will be rejected by
PMS (never transmitted), PMS (never transmitted),
Clearing house and Clearing house and
insurance/payer insurance/payer

 A claim rejection occurs prior  A claim rejection occurs prior

to claim processing to claim processing
 TOP GENERIC REJECTIONS

 ELIGIBILITY

 PRIMARY PAYMENT INFORMATION

 PAYER INFORMATION

 PROVIDER INFORMATION

 MISSING OR INVALID PATIENT INFO

 MISSING OR INVALID CLAIM INFORMATION

ELIGIBILITY
 Eligibility : Rejection Reasons

Member not eligible

Policy Cancelled

Patient/Subscriber not found in payer

database
Subscriber Eligibility not found for DOS
 Eligibility:Clearing House Rejection
Phrases
Entity not eligible for benefits on submitted Dates of service

Claim has been Rejected as Unprocessable. Policy Cancelled

Patient eligibility not found with Entity.

Subscriber/Patient not found in payer database

 Eligibility - Actions
Analyze Resolve
 If policy termed and no other insurance
 Verify Eligibility with Insurance
available, task client or bill patient ( Client
 Obtain the Termination/Effective protocol )
Dates  If policy number is incorrect, correct the
 Verify if the policy not active for our same and resubmit claim
DOS billed  If new policy # obtained for the same
 Verify if we billed with incorrect Insurance, update the same in patient files
 Refile the claim
member id
 If new insurance details obtained in patient
 If not active for DOS, verify if the ID
files, verify and confirm eligibity
# changed for the policy.  Update the new Insurance, Verify TFL and
 If yes, verify Eligibility with the new resubmit the claim
id.  If no Insurance details available, Task client
 If policy not active, check patient or Bill patient ( Client protocol )
files to obtain any other Insurance
details for the patient
PRIMARY PAYMENT
INFORMATION
Primary Payment Info : Rejection Reasons

Primary Adjudication Missing

Primary Payment and Co-Insurance does

not match with Allowed
Claim submitted within 30days from
Primary Adjudication
Primary Payment Info:Clearing House
Rejection Phrases
 COB balancing error. The Payer paid value does not equal the Line Charge minus the adjustments on Line

1.

 Service Line Paid Amount

 Medicare Report Number is required.

 Payer does not allow secondary claims to be submitted before 30 days after previous adjudication of

Medicare Primary claim.

 Payer requires claim paid amount + claim adjustments + line level adjustments equals claim charge.

 Line Adjudication claim adjustment reason is Invalid.Must be @ ADJ

 Claim out of balance

 Claim submitted without Medicare Adjudication information. Medicare must process the claim first.
 Primary Payment Info -
Actions
Analyze Resolve
 Rejections occurs with secondary
 Correct the charges in secondary claim
Insurance, when the Primary processed matching Primary processed EOB -
information updated incorrectly Billed, write off, allowed, coinsurance,
 Verify the primary paid and paid etc
coinsurance matches the allowed  Update Adjustment and reason codes
amount such as PR 1, PR 2 , CO45 etc on the
 Verify the allowed amount and write off secondary claim as per the Primary EOB
matches the primary billed amount  If an auto cross over made by Medicare,
 Check if the secondary claim is an auto allow 30days from Primary processed
cross over from Medicare and we billed date for secondary to process.
within 30days from Primary processed  Match the billed, allowed, coinsurance,
date. adjustments and reason codes as per
 Check if the Adjustment codes updated the Primary EOB and resubmit the
correctly in the claim claim.
PAYER INFORMATION
 Payer Info : Rejection Reasons

Invalid Primary Payer Identifier

Invalid Secondary Payer Identifier

Payer Zip code Incorrect

Check if incorrect DME Jurisdiction billed

Payer does not have Electronic Setup

 Payer Info:Clearing House Rejection
Phrases

 Claimant is out of Jurisdiction for this Region

 Payer Name Matching required

 Provider NPI for Payer ID has not been completed and

enrollment is required
 Destination Payer Primary Identifier Invalid; Must be a valid
Payer Id from the Payer list.
 Claim information for Carrier is not entered
 Payer Info - Actions
Analyze Resolve
 Identify the payer id from patient files
 Check if Insurance payer id is
 Update the same in the claim as well as in
incorrect. Insurance masters
 We may have many records under a  Refile the claim
single Insurance name  Check if incorrect Insurance chosen. Validate
 Verify patient files to confirm that we Insurance based on address and payer id.
were billing the correct insurance  Update the correct Insurance and refile the
and the payer id matches with claim
patient records.  If patient jurisdiction is under another
 Check if Insurance mailing address is Insurance plan, update the same in claim as
well as in Patient masters, resubmit the
incorrect in the claim. claim.
 Check if we need to bill other region  If payer does not have electronic setup,
based on patient location initiate the submission through paper.
 Check if the payer has electronic  Make sure to change the submission type in
setup to transmit electronically. Insurance level as well to avoid future
rejections
MISSING / INVALID
PATIENT INFO
Missing/Invalid Patient info: Rejection
Reasons
 Missing / Invalid Subscriber ID

 Subscriber details missing

 Patient information missing

 Gender missing/mismatches

 Insurance not available in patient screen

 Other insurance information incorrect

 Member id inconsistent with patient name and DOB

Missing / Invalid : Subscriber/Patient Info

COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Subscriber last name required to be present. Subscriber id qualifier is required to be present. Subscriber

relationship to the patient is required to be present.

 Subscriber and Subscriber id is invalid

 Member id is Invalid. Invalid data

 Subscriber Member number does not match allowable patterns.

 Entitys contract/member number - Insured/Subscriber

 Subscriber and Subscriber ID mismatches

 Patient/Subscriber Gender Code is required to be present

 Other Insurance Subscriber last name required to be present. Other Insurance Subscriber id qualifier is

required to be present. Other Insurance Subscriber relationship to the patient is required to be present.
Subscriber Details Missing/Patient Information
Missing
COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Subscriber last name required to be present. Subscriber id qualifier is required to be present.

Subscriber Id is required to be present. Patient relationship to Insured is required to be Present.

 Subscriber / Patient City is required to be present . Subscriber / Patient state is required to be

present. Subscriber / Patient Zip is required to be present

 Other Individual relationship code is Invalid: Other Subscriber Last name is required to be present:

Other Subscriber Id qualifier is required to be Present. Other Subscriber id is Required to be Present

 Subscriber and Policy number / Contract number not found

 Length of Subscriber Id must be greater than 2 but less than 80. Required if Subscriber is a person

 Subscriber and Subscriber Id not found

 Missing / Invalid Subscriber ID
Analyze Resolve
 Verify if id number updated  If Id # updated incorrectly, update
incorrectly in the Claim. the correct id #
 Check if any other details of  Refile the claim
patient/subscriber seems to be  If found patient name/DOB
incorrect incorrect, correct the same as per
 Check if patient name/DOB is Demo and refile the claim
incorrect  If no details available, task client or
 Verify insurance eligibility with
bill patient ( Client Protocol )
Name/DOB combination to obtain
valid id number.
 Check if policy number changed
within Insurance.
 If yes, verify Eligibility with the new
id.
 Subscriber/Patient Details Missing -
Actions
Analyze Resolve
 If details missing in the claim, update the same
 Verify if any patient information and refile the claim
missing in the claim  If details updated incorrectly such as DOB,
 Verify if subscriber information Address or relationship etc, check patient files
updated correctly and obtain the correct information.
 Update claim with proper information and
 Check if patient name, DOB, resubmit claim.
address, Zip code, Gender,  If information obtained through website, update
relationship updated correctly. the details and resubmit the claim
 If any details missing/incorrect,  If no data found, task for calling assistance
check the Patient files to obtain the  Always, remember to update the fields which
impact future dos such as SO, patient insurance
correct information.
information screen etc to avoid future
 If cannot find details in patient files, rejections/denials
try verifying eligibility using member
id in website and obtain the patient
information through website.
 Insurance information/Other Insurance
information missing

COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Other Insurance Subscriber last name required to be present. Other

Insurance Subscriber id qualifier is required to be present. Other

Insurance Subscriber relationship to the patient is required to be present.

 Insurance Carrier Name Missing

 Claim information for Carrier is not entered

 Claim submitted to Incorrect Payer

 Insurance information/Other Insurance
information missing - Actions
Analyze Resolve
 Validate patient information with Patient files /
 Check if Insurance information Insurance and update the same in Insurance
updated in the patient screen. screen
 Check if secondary or other insurance  Update claims with the same and refile the
claims
details along with the subscriber  If found we are innetwork with the DME
details are missing contractor, update the changes in patient
 If information available, verify if the screen as well as the claim and refile claims
 If found we are OON with the DME contractor,
same is valid as per the patient files.
Notify client for assistance
 Check if claim submitted to incorrect  If unable to obtain the details about the DME
payer ( If Insurance has specific contractor in patient files, Task for AR assistance
contractor to process DME claims,
need to bill the specific contractor )
 Check if we have any DME contractor
information in patient files.
 Insurance Claim information
COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Procedure Code has an Invalid Diagnosis Pointer

 Principal Diagnosis code

 Dx code invalid for patient's Age

 Healthcare Diagnosis Code is Invalid: Must be a valid Dx code for the Date of service billed

 ICD 10 principles prohibits using the Diagnosis code as primary Dx for Dates of service

 Detailed Description of Service

 Payer requires Non specific Procedure Code has a description

 Claim rejected as Unprocessable. Rejected for Invalid Information : HCPCS

 Payer does not accept this Procedure Code

 Insurance Claim information
COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Procedure Code Invalid ; Must be a valid Procedure code for DOS

 Procedure Modifier for the services rendered

 Rejected for Invalid Information

 Procedure modifier rejected as invalid for this Payer

 Missing/ Invalid Information : Missing Appropriate modifier

 Invalid CPT modifier

 Missing NDC number

 Service Date Invalid - Must be prior or equal to Transaction set date

 Service TO Date is later than Today's Date

 Missing Authorization
 Claim Information -
Modifier/Procedure/Diagnosis - Actions
Analyze Resolve
 Update Dx pointer to notify the actual Dx for the
 Check if claim missing the Diagnosis
claim
Pointer to notate the exact diagnosis for  If Dx is incorrect and valid dx identified in
the claim patient files, update the same
 Verify the Dx billed and validate the same  Also update the patient files with the same
 Check if modifiers billed as per Insurance information to avoid future rejections
 Update modifiers as per the Insurance
guidelines
guidelines, Bill Type and Authorization in the
 Check if item billed as purchase but claim and in the patient files
insurance guidelines is rental  If any modifier is required for certain HCPCS for
 Verify if modifiers updated as per entire patients by that Insurance, update the
Authorization received same in Insurance masters to avoid future
rejections and alert billing team regarding the
 Check if the Procedure Code is a covered
same
code per Insurance policy  If any Dx or Procedure is no more active and has
 Verify if any replacement code available been deleted from Insurance coverage
with the LCD guidelines, Update new code and refile the
claim.\
 Claim Information - Description of
Service/NDC code / Authorization/Span
Dates - Actions
Analyze Resolve
 If missing authorization, task PA team or client
 Check if claim missing the for assistance ( As per client protocol )
authorization number  If authorization available but not for our
 Check if authorization available in Procedure code but for relevant procedure,
obtain client approval and change HCPCS
patient files for our Procedure code  If authorization expired, task PA team or client
 Verify if authorization number is valid for assistance (As per Client protocol)
for DOS  If authorization available, update the same in
the claim and resubmit
 Verify if authorization is expired for  Identify the Drug code from medical docs,
the service update the same in the claim and resubmit
 Medication drugs requires NDC codes.  If missing Drug Code, task client
 If Span dates not approved by Insurance,
 Check if claim billed with Span dates
Change FROM and TO dos as same and
and whether insurance does not resubmit
accept Span dates setup.  If the From DOS is future dos, validate DOS as
per delivery ticket, hold DOS and transmit after
the DOS
 PROVIDER
INFORMATION
Missing/Invalid Provider Info: Rejection
Reasons
 Missing Billing Provider Info
 Missing Ordering Physician
 Provider Enrolment for Electronic submission
 Missing Physician/Provider NPI
 Missing/Invalid Physician/Provider name and address
 Mismatching Provider address and Zip code
Missing / Invalid : Provider Information

COMMON REJECTION PHRASE FROM CLEARING HOUSE:

 Enrollment for Provider Number : NPI for Payer Id has not been

completed and enrollment is required

 Billing Provider NPI is required for this Payer

 The Claim level Referring Provider and Ordering Provider NPI is invalid

 Doctor Zip and City not entered

 NPI invalid. Must be 10 numeric digits

 Missing / Invalid Provider Info
Analyze Resolve
 If provider information(name, npi, address)
 Verify if physician information is updated incorrectly, correct the same and
updated as per the documents refile the claim
 Check if claim missing any  If missing physician information and cannot
find in documents, task client for assistance
provider info such as name,  If provider not enrolled for Electronic
address, NPI submission, change the submission type to
 Check if provider is enrolled for Print and update the same in masters to
Electronic submission avoid future rejections.
 If only electronic claims accepted by
 Verify if the NPI updated on the
insurance and provider does not have
claim is valid for the Electronic set up, task client for assistance
physician/provider billed  Update valid NPI and resubmit claim