When a claim comes back unpaid, the first useful question is what kind of problem it is. Rejections and denials are often mentioned together, but they are handled differently.
Rejections and denials
In general terms, a rejection is a claim that is returned before it is processed, usually because of a problem with the data in it. It can often be corrected and sent again. A denial is a payer decision not to pay all or part of a claim that has been processed. It may need documentation, an explanation or an appeal.
Frequent causes
The reasons below are common in general terms. Each payer has its own rules, so they are a starting point and not a complete list.
- Registration errors: a misspelled name, a wrong date of birth or an outdated identifier.
- Coverage problems: the plan was inactive, or had changed since the last visit.
- Missing authorization: a service needed approval that was not obtained or recorded.
- Documentation gaps: information needed to support a service was incomplete or unclear.
- Coding mismatches: codes that do not agree with each other or with the documentation.
- Missed deadlines: a claim or an appeal was submitted after the payer's time limit.
Habits that help
Most of these causes start before the claim is created. Checking coverage before a visit, confirming authorization where required, and reviewing documentation before coding all reduce the number of claims that come back. Keeping a record of the reasons claims return also helps, because patterns point to the step that needs attention.
When a claim does come back, a regular routine matters more than speed alone: identify the reason, correct what can be corrected, note the deadline, and record what was done.
This article is general information about healthcare business operations. It is not medical, legal or financial advice.
