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.

    • 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.

Best Practice  for Payer Rejections (PE)

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.

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