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.
Do not confuse this with a Payer Denial, which is totally different.
Payer Rejected Claims are not adjudicated and, therefore, are not in the Payer's System.
If you call the Payer on this Claim, it will not be found in their system.
The Payer should be able to tell you what the rejection message means in general.
Do a manual Real Time Claim Status check (This is an add-on premium feature).
A manual check usually gives a more comprehensive and understandable response.
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.