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.
Notes
A Payer Rejection is not the same as a Payer Denial. A rejection gets kicked back before it enters the Payer's system. A Denial has been adjudicated, and Payment has been denied.
  • 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 a Premium Add-On Feature).

  • A manual check usually gives a more comprehensive and understandable response.

Common Reasons Claims are Rejected

  • Check the Information on the Insurance Card.
  • Member ID
  • Policy Holder
  • Check the Payer ID
  • Check the Patient Information.
  • Date of Birth (DOB) is a common reason for rejection.
  • The Insured's or Patient's Name is not the same as the Insurance Information.
  • 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.

Multiple Payer Rejections

Claims correctly show all relevant rejection details, even if they came from separate files.

  • If a Claim is rejected again in the same batch with a new reason, the new note will automatically be added to the Claim’s status.
  • If the rejection note remains the same, no changes occur.
  • If the rejection comes from a different batch, the System will create a new Claim Status Record.
  • Duplicate and redundant notes won't appear twice.


Learn More

Denial Worklist Overview

Add a Manually Posted Insurance Denial to a Worklist


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