Claims Rejection & Denial Management

Claim Rejection

Claim rejection in medical billing occurs when an insurance company or payer does not accept a submitted claim due to errors or issues identified during the initial processing phase. A rejected claim has not been processed, meaning it hasn't been considered for payment because it didn't meet the basic requirements set by the payer.  

Common Reason for Claims Rejection.

1.  Incorrect or Missing Information.
   
2. Coding Error
   
3. Invalid or Expired Insurance Information.
4. Duplicate Claims
5. Format Error
6. Pre-Authorization issues.

Denials Management

 Claim denial in medical billing occurs when an insurance company or payer processes a claim but decides not to pay for the services or only partially reimburses the healthcare provider. Unlike claim rejection, where the claim isn't even processed due to errors, a denied claim has been evaluated and found to have issues that prevent full payment.

Common Reason for Claims Denials.

1. Lack of Medical Necessity 
2. Coverage issues
3. Incorrect Coding
4. Pre-Authorization Not Obtained
5. Exceeding Coverage Limit
6. Provider Out Of Network
7. Timing filling issue
8. No Referral or PCP selection Issue
9. COB Not Updated.