Fixing Most Common Claim Rejections: 2024 Update
Introduction
Claim rejections can be a major headache for healthcare providers, delaying payments and impacting revenue. Once you understand the reasons, addressing and rectifying common claim rejections is a manageable task. This updated guide for 2024 covers the top five common claim rejections you might encounter, along with practical tips to resolve them and prevent future errors.
5 Most Common Claim Rejections
1. Payer ID Mismatch
This rejection occurs when the payer ID used on your claim doesn’t match what the payer needs for electronic submissions. Each payer and clearinghouse may have different IDs, so it’s crucial to use the correct clearinghouse payer ID when submitting electronically. Remember, the clearinghouse acts as a middleman, forwarding your claim to the payer using their internal ID. You can avoid this rejection by contacting your payers directly or you can simply download their provider manuals.
2. Subscriber ZIP Code Error
An invalid ZIP code, missing the 9-digit format or extension, can trigger this rejection. While some payers still accept 5-digit ZIP codes, it’s best practice to always submit the full 9-digit format to avoid delays. Tools like the United States Postal Service Zip Code Lookup can help verify accuracy.
3. Invalid Subscriber Identifier
This broad rejection can have several root causes:
- Wrong Payer ID: Double-check the payer ID, especially if you submitted claims for multiple patients.
- Patient ineligibility: Verify the patient’s demographics and insurance policy validity for the date of service.
- New-born or recently added insurance: Contact the payer to confirm active coverage for the patient under the guarantor’s policy.
The resolution will depend on the cause. Always verify patient eligibility through provider portals or payer websites. You can contact the payer for newborn or recently added policy cases.
4. Billing Provider NPI Issue
Missing or invalid provider NPI is one of the most common claim rejections. Ensure you’re using the NPI on file with the specific payer you’re submitting to. Remember, payers also consider your Tax ID, so ensure that matches their records as well. Use the NPI lookup tool to verify provider information.
5. Diagnosis Code Invalidity
This rejection can occur due to incorrect or outdated diagnosis codes. Remember:
- Validate code activity: New, changed, and deactivated diagnosis codes are released annually on October 1st. Use ICD-10-CM code sets and CMS official coding guidelines to confirm active codes for the service date.
- Ensure code consistency: Cross-check the diagnosis code with the procedure performed to avoid inconsistencies.
- Use the correct version: ICD-10 codes are crucial. Verify you’re using the valid version for the service date (ICD-10-CM for dates October 1, 2015, to current).
Addressing common claim rejections is a critical but time-consuming process. PrimeCare specializes in streamlining this task, reducing common claim rejections, and ensuring the submission of clean claims. Contact us today to explore our comprehensive medical billing and coding solutions.
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