The Common Causes of Rejected Medical Claims

Medical claims are often denied or rejected for several reasons, from missing information to due-date errors. To ensure your claims are correctly processed and reimbursed quickly and accurately, it pays to know the most common rejection causes. Learn what triggers medical claims rejections, as well as tips on how to avoid them in the future.

Insufficient Documentation

Insufficient documentation is one of the biggest reasons why medical claims are rejected. It’s important to ensure all the required information is included when submitting claims, such as the patient’s name, date of service, type of visit or treatment, diagnosis codes, and any notes relevant to services rendered. Providers must also ensure that all patient signatures are on file and that there are no discrepancies between the documentation in their electronic health record (EHR) system and what is sent to payers.

Client Not Covered By Insurance

An all too common reason for a rejected medical claim is that the patient is not covered under the insurance plan. Make sure to obtain all required information from patients before rendering services, such as valid insurance cards, so that you can easily confirm coverage. When in doubt, call the payer to verify the patient’s policy is active and primary. Also, be aware of any out-of-network providers that may have been selected, and ensure that this information is included in your billing system.

Incorrect Claim Details

It is important to ensure that the details on your claims match up with the patient’s insurance information, as any discrepancies can lead to rejected claims. Ensure all claim forms are completed accurately and thoroughly, or they will be rejected. This includes correct dates of service, diagnosis codes, procedure codes, the beneficiary, and the covered person’s name. Additionally, take care in verifying patient identification numbers and make sure any co-pay amounts are noted correctly.

Missing or Incomplete Pre-authorization Requirements

The most common rejection you’ll face is related to missing pre-authorization requirements. These paperwork and process errors can be easily avoided by having patients provide the necessary information before service or submitting the claim for reimbursement. When filing a claim, you must include appropriate pre-authorization documents such as referral forms from their primary care physician or health plan identification cards.

Invalid Diagnosis Codes

Another common cause of rejected claims has to do with diagnosis codes. All claims must include an accurate diagnosis to assign the codes correctly. The wrong diagnosis code or an inaccurate one can lead to a denial. To avoid this, always double-check that the codes have been entered correctly and are updated with the latest version of the International Statistical Classification of Diseases (ICD) publication. Hiring a code auditor can prevent many rejected claims.