Payer Rejections Overview

Payer Rejections Overview

Payer Rejections 

When a Claim is submitted electronically, the information on the individual Claim is matched with the information the Payer has on file. If the information is not in alignment with the Payer Information, the Claim is rejected and not accepted for adjudication.

  • Payer Rejected Claims are not adjudicated and, therefore, are not in the Payer's System.

 

 Common Reasons Claims are Rejected 

  • Insurance Information is not correct.

    • Member ID

    • Policy Holder

    • Sent to wrong Payer (check the Payer ID).

  • Patient Information

    • Date of Brith (DOB) is incorrect.

    • Name is not the same as the Insurance Information.

    • Wrong Patient address.

  • Diagnosis/Procedure Codes

    • Invalid/Inactive Procedure Code

    • Invalid/Inactive Diagnosis Code

    • Modifier is incorrect or required.

  • Taxonomy

    • Incorrect Taxonomy Code

    • TIN or NPI is not on file with the Payer.

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