Customer Service

Rejected Claims

CODING

  1. Rejections for coding errors are related to payers not accepting information contained in Box 24. HealthFusion scrubs your claim for CPT, ICD and modifier codes based on the valid codes for the date of service submitted. These code scrubs do not always prevent a payer from rejecting certain codes even if the codes are valid. The payer may only allow a subset of the code database based on their own adjudication rules.
  2. Some helpful hints related to coding errors:
    1. Always make sure you use codes that are accepted by your payers (check with your payers before submitting claims)
    2. Make sure your place of service is accurate for the claim you submit
    3. Make sure your CPT and ICD codes are age and sex compatible
    4. Some payers allow just 4 or 6 diagnosis pointers and will reject the claim for invalid or too many diagnosis codes and pointers
  3. If you are rejected for a Coding error, it is best to call the payer first and they will have the best explanation as to why your claim was rejected.

DATES

  1. Payers will reject claims that have procedure codes that require a date if the date is missing or invalid. Most of the time the date should have been placed in Box 16, 18 or 19 (if you are editing claims in the edit claim screen on our portal)
  2. Below is a list of common reasons why your claim may be rejected for the Dates reject category:
    1. Missing manifestation date for acute condition
    2. Accident indicator and date were required
    3. Date of illness was after service date on line charge
    4. The claim was missing the date of current illness onset
    5. An admission date was required
    6. Transaction date was before the birth date
    7. Date of service was later than the discharge date
  3. If you are rejected for a Dates error, it is best to contact HealthFusion first and let us try to assist you prior to you calling the plan.

DUPLICATE CLAIM

  1. The HealthFusion duplicate claim screening process usually prevents this type of rejection. If you see this type of rejection it may be related to a claim that was sent both on paper and electronically. If your practice only sent one claim and you are getting rejection for duplicate it could be related to an error at the payer’s gateway.
  2. If you are rejected for a Duplicate Claim error, it is best to call the payer first and they will have the best explanation as to why your claim was rejected.
  3. Hint: some payers may accept your claim if you change the charge amount (even by one cent).

ELIGIBILITY

  1. The most common reason why a claim is rejected at the payer’s gateway is related to an eligibility problem. Usually this is because the payer has determined that the patient was not eligible for the dates of service submitted in the claim. Sometimes the user has mis-keyed the member ID information in the claim. Please verify that the member ID on your copy of the member ID card matches the data on the claim.
  2. To avoid this error use HealthFusion’s real time eligibility check for all payers supported and call for eligibility on the other plans.
  3. If you are rejected for an Eligibility error and you are convinced that the patient is eligible then it is best to call the payer first and they will have the best explanation as to why your claim was rejected.

PAYER

  1. Rejections related to Payer usually mean that the claim was sent to the incorrect payer or that the payer information was incomplete or invalid.
  2. The most common reasons why a claim is rejected for payer is as follows:
    1. The group number is missing or invalid (Box 11)
    2. COB information is missing or invalid
    3. The claim was sent to the incorrect Tricare division
    4. Medicare was billed in the wrong order
  3. If you are rejected for a Payer error, it is best to make sure that the correct payer was billed. You may want to contact the patient and confirm the payer billing information. If you believe that all of the payer data is correct then it is best to call the payer, they will have the best explanation as to why your claim was rejected.

PROVIDER

  1. The second most common reason why a claim is rejected at the payer’s gateway is related to a problem with one of the provider fields. The Provider reject category can be caused by a provider data error in any of the commonly used provider identification fields. Those fields include:
    1. Billing Provider (Box 33)
    2. Rendering Provider (Box 31)
    3. Referring Provider (Box 17)
    4. Service/Facility (Box 32)
  2. Common reasons for provider related rejections errors include:
    1. Your NPI or Tax ID is not on the Payer X-Walk or the NPI Database X-Walk.
    2. For Medicare – your NPI, Tax ID and your Medicare ID must match the NPI Database National Plan and Provider Enumeration System (NPPES).
    3. Medicare Contractors are turning on edits to begin validating the NPI/legacy pair against the Medicare NPI Crosswalk. If the pair on the claim is not found on the crosswalk, the claim will reject.
    4. You must not confuse your Group ID (Box 33) with your Individual ID (Box 31) and if you use a Group NPI and Individual NPI they must be placed in the proper location on the claim – this is true for all payers including Medicare.
    5. HealthFusion is not allowed to register your providers on a Payer X-Walk or at the NPI database.
    6. Do not make the mistake of assuming that if you register your NPI with the NPI enumerator that you have also registered with the payer. You must register your NPI with each payer you submit to.
  3. For plans that require enrollment, your group and each provider must be enrolled in the plan. Your practice must use the same identifiers in their claim submission that were used in the enrollment process.
  4. The naming convention for the Billing Provider (Box 33) should stay consistent. If you send Smith, John always send the name in that order. Example: do not send John Smith. Many payers alias your Billing Provider name precisely, so consistency in this field will pay off!
  5. Always identify the Referring Provider with their ID in addition to their name. It is now appropriate to use the Referring Provider NPI for most payers.
    1. Any provider can be found in the NPI database, Search the National Plan and Provider Enumeration System (NPPES).
    2. Many payers and almost all Medicare Intermediaries reject the non-specific UPIN OTH000
  6. Until May 23, 2008 include your legacy ID only for payers that still require the ID. For Medicare please read the following:

    Effective March 1, 2008, your Medicare FFS claims must include an NPI in the primary provider fields on the claim (i.e., the billing, pay-to provider and rendering provider fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI. The secondary provider fields (i.e., referring, ordering and supervising) may continue to include only your legacy number, if you choose. Failure to submit an NPI in the primary provider fields will result in your claim being rejected, beginning March 1, 2008. Also, as of May 23rd, 2008 Medicare will not allow any legacy ID’s on the claims, NPI only, including the referring provider field.

  7. Provider Error Checklist:
    1. My provider IDs are registered with the payer and the NPI database
    2. I used the appropriate group number in the Billing Provider (Box 33)
      ID field and the Individual ID in the Rendering Provider (Box 31) ID field
    3. I am enrolled with HealthFusion for the plans I am submitting to and my IDs in my claim match the IDs that I used in my enrollment
    4. I am always formatting the Billing Provider Name field the same way and the format for the field matches claims that have already been accepted by that payer
    5. I have identified the Referring Provider (Box 17) properly and if I get a rejection for the Referring Provider (Box 17). I understand that I can send the NPI in that field for most payers, I know I can find the NPI for any provider on the Search the National Plan and Provider Enumeration System (NPPES).
  8. If you are rejected for a Provider error, it is best to contact HealthFusion first and let us try to assist you prior to you calling the plan.