What is Rejection? & How to work on Rejections?
- Rejected claims are those that never entered into the insurance processing system for processing and such claims get rejected through PMS (Software) or Clearinghouse.
- A Claim needs to be passed successfully through software, provider clearing house & insurance clearing house to enter into the insurance processing system. If a claim fails to pass any of these 3 systems then we get a rejection.
- There are 3 types of rejections:
- Rejected by PMS (Software) - These claims do not go out of the software since they get rejected by PMS only.
- Rejected by Provider Clearing House - These claims are successfully passed through software but rejected by the provider clearing house.
- Rejected by Insurance Clearing House - These claims are successfully passed through software and provider clearing house but rejected by the insurance clearing house.
Below are a few most common rejections with resolution steps:
1) Policy ID invalid / Patient or Subscriber not identified:- These rejections generally occur due to 2 reasons,
- When a claim is billed with an incorrect policy ID
- When a claim is billed to an incorrect payer ID
- In the clearing house, there is already a policy ID format set up related to an insurance company that needs to be followed when billing claims.
- For Example - The format for the policy ID of UHC is 9 digits number, so if the claim is billed with 10 digits number then it gets rejected for invalid policy ID format.
- Resolution: You can utilize the payer website to find out the correct policy ID and resubmit the claim with the correct policy ID.
- If the website access is not available then you can check the insurance history or payment history to find out the correct policy ID.
- If you are unable to find the correct policy ID then check your insurance history for another active primary insurance.
- If you are able to find another insurance then check the eligibility and resubmit the claim to the new insurance if it is active.
- If another insurance is not active on DOS then release the claim to the patient. (Follow your client update before releasing the claim to the patient)
- Below is the list with the correct policy ID format of payers that will be helpful to identify the correct policy ID,
Insurance |
Policy ID Format |
Policy ID Examples |
1199 SEIU FUNDS |
10 digits number |
1234567890 |
AARP |
11 digits number |
12345678901 |
Aetna |
10 digits alphanumeric characters (1st character
always a letter "W") |
W123456789 |
Aetna Medicare |
8 digits alphanumeric characters |
ABCDEF1G OR ABCDE1FG OR ABCDE12F OR ABCD123E OR
ABCD12EF OR ABCDEFGH |
Affinity Health Plan |
11 digits number |
12345678901 |
All Saver |
9 digits alphanumeric characters (1st character
always a letter "C") |
C12345678 |
Amerigroup |
9 digits number |
123456789 |
AVMED |
11 digits alphanumeric characters (1st character
always a letter "A") |
A1234567890 |
Bankers Fidelity Life OR Bankers Life &
Casualty |
10 digits number |
1234567890 |
BCBS |
12 digits alphanumeric characters (1st 3
characters are always letters) |
ABC123456789 |
BCBS |
14 digits alphanumeric characters (1st 3
characters are always letters) |
ABC12345678901 |
BCBS FEP |
9 digits alphanumeric characters (1st character
always a letter "R") |
R12345678 |
Cigna |
9 digits alphanumeric characters (1st character
always a letter "U") |
U12345678 |
Colonial Life |
9 digits number |
123456789 |
Emblem Health |
9 digits alphanumeric characters (1st character
always a letter "K") |
K12345678 |
Fidelis Care |
11 digits alphanumeric characters (1st digit
always a letter "7") |
7123456789 |
Fox Everett |
9 digits alphanumeric characters (1st 2
characters are always letters "FE") |
FE1234567 |
Freedom Health |
11 digits alphanumeric characters (1st character
always a letter "P") |
P1234567890 |
GEHA |
8 digits number |
12345678 |
GHI |
9 digits number |
123456789 |
Golder Rule |
9 digits number |
123456789 |
Humana |
9 digits alphanumeric characters (1st character
always a letter "H") |
H12345678 |
Mail Handlers Benefit Plan |
11 digits number |
12345678901 |
Medicaid AK |
10 characters in length, containing only numbers |
1234567890 |
Medicaid AL |
13 characters in length, containing only numbers |
1234567890123 |
Medicaid AR |
10 characters in length, containing only numbers |
1234567890 |
Medicaid AZ |
9 characters in length, containing both letters and
numbers. 1st character is always a letter (compulsory "A"). |
A12345678 |
Medicaid CA |
It has 2 formats, I - 14 characters in length, and contains both letters and numbers. The 9th character is always a letter. II - 9 characters
in length, containing both letters and numbers. The 9th character is always a letter. |
12345678A01234 OR 12345678A |
Medicaid CO |
7 characters in length, containing both letters and
numbers. 1st character is always a letter. |
A123456 |
Medicaid DC |
8 characters in length, containing only numbers |
12345678 |
Medicaid FL |
10 characters in length, containing only numbers |
1234567890 |
Medicaid GA |
12 characters in length, containing only numbers |
123456789012 |
Medicaid HI |
10 characters in length, containing both letters
and numbers. 2nd character is always a letter. |
1A234567890 |
Medicaid ID |
10 characters in length, containing only numbers |
1234567890 |
Medicaid IL |
9 characters in length, containing only numbers |
123456789 |
Medicaid IN |
12 characters in length, containing only numbers |
123456789012 |
Medicaid KY |
10 characters in length, containing only numbers |
1234567890 |
Medicaid LA |
13 characters in length, containing only numbers |
1234567890123 |
Medicaid MA |
12 characters in length, containing only numbers |
123456789012 |
Medicaid MD |
11 characters in length, containing only numbers |
12345678901 |
Medicaid MI |
10 characters in length, containing only numbers |
1234567890 |
Medicaid MN |
8 characters in length, containing only numbers |
12345678 |
Medicaid MS |
9 characters in length, containing only numbers |
123456789 |
Medicaid NC |
10 characters in length, containing both letters
and numbers. The 10th character is always a letter. |
123456789A |
Medicaid NH |
10 characters in length, containing only numbers |
1234567890 |
Medicaid NJ |
12 characters in length, containing only numbers |
123456789012 |
Medicaid NM |
14 characters in length, containing only numbers |
12345678901234 |
Medicaid NV |
11 characters in length, containing only numbers |
12345678901 |
Medicaid NY |
8 characters in length, containing both letters and
numbers. 1st, 2nd, and 8th characters are always letters. |
AB34567C |
Medicaid OH |
12 characters in length, containing only numbers |
123456789012 |
Medicaid OR |
8 characters in length, containing both letters and
numbers. 1st, 2nd, 6th and 8th characters are always letters. |
AB345C6D |
Medicaid PA |
10 characters in length, containing only numbers |
1234567890 |
Medicaid TX |
9 characters in length, containing only numbers |
123456789 |
Medicaid UT |
10 characters in length, containing only numbers |
1234567890 |
Medicaid VA |
12 characters in length, containing only numbers |
123456789012 |
Medicaid WA |
11 characters in length, containing both letters
and numbers. 10th and 11th characters are always letters (compulsory
"WA"). |
123456789WA |
Medicaid WV |
11 characters in length, containing only numbers |
12345678901 |
Medicaid WY |
10 characters in length, containing only numbers |
1234567890 |
Medicare |
11 digits alphanumeric characters ((1st, 4th,
7th, 10th & 11th characters are always numbers) (2nd, 5th, 8th & 9th
characters are always letters) & (3rd & 6th characters are either
numbers or letters)) |
1AB2CD3EF34 OR 1A23B45CD67 OR 1A23CD4EF56 OR
1AB2C34EF56 |
Meritain Health |
10 digits number |
1234567890 |
Optimum Health |
11 digits alphanumeric characters (1st character
always a letter "T") |
T1234567890 |
Oxford |
10 digits number |
1234567890 |
UHC |
9 digits number |
123456789 |
UMR |
8 digits number OR 9 digits alphanumeric
characters (1st character always a letter "Y") |
123456789 OR Y12345678 |
- When a claim is billed to an incorrect payer ID then also we get this rejection.
- For example, UHC payer ID is 87726 and the claim was billed to payer ID 95226.
- Resolution: You can find out the correct payer ID and resubmit the claim.
- On the below link, you will get the list of payers with their payer ID that will be helpful for correct submission,
- This rejection occurs when a patient does not have an active policy on DOS.
- Resolution: You can utilize the payer website to find out the correct name or DOB and resubmit the claim with the correct information.
- If the website access is not available then you can check the insurance history or payment history to find out the correct Name or DOB.
- If you are unable to find the correct information then check your insurance history for another active primary insurance.
- If you are able to find another insurance then check the eligibility and resubmit the claim to the new insurance if it is active.
- If another insurance is not active on DOS then release the claim to the patient. (Follow your client update before releasing the claim to the patient)
- This rejection occurs when a patient does not have an active policy on DOS.
- Resolution: You can check patient eligibility to verify whether this is a correct rejection or not. If it is not a correct rejection and the patient is active on DOS then you need to verify that the patient demographic information (Patient name, DOB, policy ID) is correct or not. If all the information is correct then simply resubmit the claim. If you find that any particular information is not correct then make the correction and resubmit the claim.
- If the patient is not active on DOS then you can check the insurance history to find out another active insurance.
- If you are able to find another insurance then check the eligibility and resubmit the claim to the new insurance if it is active. If another insurance is not active on DOS then release the claim to the patient. (Follow your client update before releasing the claim to the patient)
- If you are not able to find any other active insurance then you can release the claim to the patient. (Follow your client update before releasing the claim to the patient)
- This rejection occurs when a claim is billed to insurance at an incorrect address. OR sometimes patient provides insurance information that is outside of the US.
- Resolution: You can try to find out the correct address of the insurance if it belongs to the US and resubmit the claim.
- If the insurance address is outside of the US then you can check the insurance history for another active insurance.
- If you are able to find another insurance then check the eligibility and resubmit the claim to the new insurance if it is active.
- If another insurance is not active on DOS then release the claim to the patient. (Follow your client update before releasing the claim to the patient)
- This rejection occurs when the patient's zip code is missing or invalid.
- Resolution:
- You can search on google with the patient's address to find out the correct zip code.
- You can check patient eligibility on the payer website to find out the correct zip code.
- You can utilize below USPS website to find out the correct zip code. You can find out the correct zip code by street address or city & state.
- https://tools.usps.com/zip-code-lookup.htm
- Once you get the correct zip code then update it and resubmit the claim.
- This rejection occurs when a claim is billed to Auto or Worker Compensation but the appropriate box is not checked on the claim form.
- On the CMS1500 form, in box# 10 an appropriate box needs to be ticked when billing to Auto or Worker Compensation insurance.
- Resolution: You can tick the correct box through the software and clearing house and resubmit the claim.
How to deal with claim rejections stating exceeds medicare timely filing limit or any other insurance TFL?
ReplyDeleteIf the denial or rejection for TFL expired is received from Original Medicare and the TFL of 365 days is expired then such claims won't get paid even if you have the POTF. Medicare does not pay any claims that are received after 365 days from DOS. It needs to be written off.
DeleteFor other insurance, if you get the rejection of TFL exceeds then you can check if you have POTF or not. If it is available then there must be an option to attach the POTF in your clearinghouse. If there is no POTF and the claim is rejected correctly then it needs to be written off.
If this rejection or denial is received from the payer then sometimes there is an option to send an appeal after providing a specific delay reason on the appeal form and some insurances do accept and pay the claim. You can also try this to get the payment.
How to work on The Rendering provider NPI is not affiliated with the submitting Group/Clinic rejection?
ReplyDeletePlease follow the below scenario to work on this denial,
Deletehttps://www.arlearningonline.com/2019/12/185-rendering-provider-is-not-eligible.html
If is there any NPI issue you can change NPI means use individual NPI or which is on going bill on your practice.
ReplyDeletePlease confirm with your client to change the NPI. But, you can share the exact rejection reason, we can try to see if there is any other possibility.
DeleteWhat is the process how can I identify rejections and denials?
ReplyDeleteIt can be identified through the software that you are using. Most of the PMS shows both rejection and denials and if it is not available in the software then you should check the clearing house where you can determine whether a claim has been rejected or denied.
Delete