Payer Rejection: Reason Not Clear
Payer Rejection prefixes:
- EP: Third-Party Clearinghouse
- AP: Payer
Payer Rejections can be more difficult to read as they often do not comply with standard responses.
- 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.
- 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.
- 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.
- 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.
- If the Representative can answer the question, ask for the ANSI Loops and Segments the information needs to be in.
- Ask the Representative if the Policy Number is the correct one to use.
- If the Representative does not give you a clear answer, ask for another Representative.
- Ask if the Payer has a website where the information can be found.
- If they do, get the website address.
- Ask for the name of the person you are speaking with.
- Get a Reference number for the call.
- 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
- If the Payer accepts paper claims, the HCFA can be mailed to the Payer.
- You may be able to file the claim on the Payer's Web Portal.