Medical Claims

# Top Reasons Why Your Medical Claims are Rejected or Denied

- December 12, 2016
- Posted by Kristen Edwards

12 Dec

If you are dealing with an increased number of rejected claims every month then you really need to delve deep into the reasons that are causing this havoc, because rejected claims and denied payments not only negatively impact your revenue cycle but in a longer course of time can hamper your business operations. However, you can rectify this and increase your reimbursements only by learning exactly about the major factors that contribute to claim rejections and payment denials. Before moving forward, we have to understand the difference between a rejected and denied claim. Claims that do not meet specific criteria for submission or lack the required documentation are rejected. They are not simply accepted by the payor or insurance company. Thus, a rejected claim can be resubmitted by fulfilling the requirements. Denied claims are however received by the insurance company, evaluated but denied due to many reasons which can range from errors in the billing or due to the objection over the patient coverage. However, you can appeal to reconsider by eliminating the reasons for the denial and resubmitting it with modifications. Below are some of the major reasons for claim rejections and payment denials.

## Rejected Claim Definition

Claims that do not meet specific criteria for submission or lack the required documentation are rejected, hence called, rejected claims. They are not simply accepted by the payor or insurance company. However, a rejected claim can be resubmitted by fulfilling the requirements.

## Denied Claim Definition

Denied claims are however received by the insurance company, evaluated but denied due to many reasons which can range from errors in the billing or due to the objection over the patient coverage. However, you can appeal to reconsider by eliminating the reasons for the denial and resubmitting it with modifications.

## 7 Major Reasons for Claim Rejection

While the rejected claim definition must have given you a basic idea of why a claim gets rejected, below we have discussed several underlying causes for it in detail;

### 1. Incorrect Patient Information

Claims with missing patient information or the details provided are simply wrong, such as their insurance ID number, policy number, complete name, date of birth or address, etc. the claims cannot be processed and are rejected at a very initial stage.

### 2. Unauthorized Service

If a service provided to a patient is not covered under the insurance policy or there was a pre-authorization required for that particular procedure, mostly on that pretext claims are rejected by the insurance companies.

source:signatureperformance.com

### 3. Missing or Invalid ICD/CPT Codes

Wrong or invalid Diagnostic Code (ICD code) or mismatching Current Procedural Terminology (CPT) code is one of the biggest reasons for claim rejections. Sometimes, conflicting modifiers can altogether confuse the treatment rendered by the physician. Moreover, if the place of service code is incorrect, the claim would be denied.

### 4. Duplicate Claims

Duplicate claims are denied because the payor had mostly already paid for the service rendered on the same date. Sometimes, physicians or providers submit the claim again because they haven’t received a response regarding it. In any scenario, you must wait for 30 days after the claim submission, and if still get no response, follow up with the customer representatives rather than send the claim again. Because duplication would open the inquiry on the payor’s end and can further delay the process.

### 5. Inaccurate Payment Details

If the billed amount is incorrect and does not correspond to the actual cost defined for the service procedures, in that case, the claims are rejected. Sometimes there are typos and spaces in the digits that cause this confusion, and the billed amount seems incorrect.

### 6. Non-credentialed Physicians

If there is a requirement by the payor for individual credentialing of the physicians in your practice, services billed for that non-registered physician would be denied. Therefore, in any situation, a physician must be registered with the payor before sending the claims for the services rendered.

### 7. Delayed Claim Submission

Most insurance carriers allow a timeframe of 60 to 90 days from the time of service to file the claim and this is a standard practice. However, for any reason you are not able to send the claim that early or took too much time for any reason, the claim would be rejected. For all that reasons, practices should timely submit their claims, after verifying that all the information is accurate.

### Lets Sybrid MD Help You Fix Your Claim Errors

Claims not paid beyond a certain date are flagged and followed up on to ensure collection. Sybrid MD follows up with each insurance company based on their specific payment schedules. We strive to keep your 60-day outstanding accounts receivable below 20%, and 120-day accounts receivable below 10%.

Sidebar Scroll To Top