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 a Payer Rejection with a Payer Denial.
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.