What is Rejection? & How to work on Rejections?

Rejection:

• 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

    I) When a claim is billed with an incorrect policy 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

    II) When a claim is billed to an incorrect payer ID:    

• 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,

• https://www.arlearningonline.com/2021/07/list-of-insurances-with-payer-ids.html

2) Subscriber Name or DOB invalid:

• 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)

3) Patient not eligible on Date of Service:

• 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)

4) Payer address invalid or incomplete:

• 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)

5) Patient/Subscriber zip code is invalid:

• 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.

6) Accident type is invalid:

• 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.