Aside from non covered services, most claim rejections start at the provider claims submissions level and don’t even reach the payer and are therefore automatically rejected. Things like errors with formatting, provider credentialing/enrollment and patient demographic/policy information; missing form data elements; code errors. If the claim makes it past the editing systems, then it may be denied for things like non covered service, lack of supporting documentation or per-certifications, additional procedural and diagnostic code errors, incorrect modifiers, units, etc. Some claims may be flagged due to prior billing patterns and will be scrutinized further for compliance and held up longer in the claims system before determinations are made.
Another reason would be when the patient information missing in the claim form. For example -Patient id, Patient DOB, Patients Address, Sometimes The rejections are Get due to Diagnosis codes are not billable or the Patient need the prior authorization on that particular treatment these are the some common rejections in medical billing.
The rejections are of 2 types. The first one is total and outright rejection of claims, and the second type is partial rejections.
Then again, the reasons for rejection can be different for claims falling in different time frames. Like claims falling into the first 30 days of the initial year of cover, first two years of initial cover term, the first three or four years of waiting period.
We will talk about the initial year first.
Any hospitalization except for accidents/mishaps during the first 30 days will be rejected mercilessly. Apart from this, the first year will also not be getting any claims for certain listed surgeries/ procedures mentioned in the policy exclusions.
Up to two complete years, no hospitalizations to treat the policy-listed surgeries/procedures will be admitted. So also any treatment of preexisting medical disorders will meet the insurer’s approval.
After two years, up-till third year (Certain policies extend it to four years) is complete, no per-existing ailments or disorders will be entertained.
Apart from this, claims can be rejected if they are fraudulently or dishonestly made.
Partial rejections can be for a multitude of reasons, like…
a) Costs for inadmissible co-morbidities (during the PED waiting period)for hospitalizations for other reasons, or
b) Proportionate reduction of claims for having availed higher than entitled category of room,
c) Inadmissible procedures listed in the policy,
d) Certain types of treatment not permitted as per policy terms, or
e) Excluded elements of treatment etc.
You submit a claim to the insurance company. You think you’ve billed the correct procedure code, with the appropriate modifiers. You’ve included diagnosis codes that meet the coverage criteria and attached a prior authorization, if required. You wait a few weeks or a month and the insurance company messages you back, either electronically or by paper. Their answer is NO. We will not pay you for the claim as it is submitted. That’s a rejection. As a medical billing company, it’s now our job to figure out what went wrong, and get that claim paid faster. For smooth and clean claims submission, please talk to our one of Billing Manager today!