Payer Rejection: Reason Not Clear

Payer Rejection: Reason Not Clear


Payer Rejection: Reason Not Clear

Payer Rejection prefixes:
  1. EP: Third-Party Clearinghouse
  2. AP: Payer

Contact the Payer

Payer Rejections can be more difficult to read as they often do not comply with standard responses.

  1. For Payer rejections that you cannot understand, you will need to contact the Payer directly if you are unsure how to make the corrections to resubmit the Claim.
  2. Keep in mind that this Claim has not entered the Payer adjudication system, therefore:
  • They will not be able to see the Claim, and
  • You will not have an EOB.
  1. Ask for the EDI Department for non-adjudicated claims.
  • Even though the Claim has not entered the adjudication system, the Payer should be able to clarify the meaning of the rejection.
  1. Have this information available:
  • Patient's name and date of birth
  • Policy Holder's name and date of birth if different than Patient.
  • Policy and Group Number.
  • Insurance Card should be loaded into the Patient Dashboard and/or the Ticket.
  • Payer Rejection Reason that was sent back into the System.
  1. If the Representative can answer the question, ask for the ANSI Loops and Segments the information needs to be in.
  2. Ask the Representative if the Policy Number is the correct one to use.
  3. If the Representative does not give you a clear answer, ask for another Representative.
  4. Ask if the Payer has a website where the information can be found.
  • If they do, get the website address.
  1. Ask for the name of the person you are speaking with.
  2. Get a Reference number for the call.
  3. Document the conversation in the Notes panel of the Encounter/Patient Dashboard and/or on the Worklist item.
  • Phone number that was called
  • Who did you speak with?
  • What is the Reference # of the call?


Options

  1. If the Payer accepts paper claims, the HCFA can be mailed to the Payer.
  2. You may be able to file the claim on the Payer's Web Portal.






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