How to Understand Claim Rejection Reasons

Since our clearinghouse has been in business for over 20 years, naturally we have connections with thousands of payers.
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As you likely know from experience, the majority of those payers have different claim submission rules and requirements…that’s likely the reason you ended up reading this in the first place.
Since we have two decades worth of experience with submitting claims on behalf of healthcare providers, we’re very familiar with claim submission requirements. In other words, I’m able to provide you with a list of the most common claim rejections we see at the clearinghouse-level.
On a payer level, claim rejections happen when what’s provided on the claim doesn’t match with what the payer has on record. They also happen when the information submitted isn’t in alignment with the payer’s electronic filing guidelines.
In either case, the claim will come back to you with a description that the payer couldn’t accept it for processing.
You would run into the same type of claim rejection on the clearinghouse level, except you’re able to change it and resubmit it instantly.
As you might’ve noticed from the table of the most common claim rejections that we see, there are a few commonalities.
First, let’s talk about rejections that list MEMBER, GROUP, PATIENT, and SUBSCRIBERS.
All three of those words identify the same person, but they change based on the payer. This field identifies the patient.
Luckily, when it’s mentioned on a claim rejection, it’s an easy fix. It tells you that you need to review the patient’s member ID card. The claim you submitted in this case likely has an error in the accuracy of what was entered about the patient’s insurance information.
Second, let’s look at rejections that list ICD, CPT, and DIAGNOSIS CODES.
Unlike the previous identifiers, these types of claim rejections aren’t interchangeable. However, they are all related.
Insurance payers stay attuned to diagnosis codes and their updates. Sometimes more specific ICD codes take the place of generic ones. When this happens, the old gets replaced with the new.
On the CPT code side of things, sometimes insurance payers will reject a claim if it contains an unauthorized CPT code or modifier combination. Payers identify those unauthorized codes within their claim filing guidelines.
Naturally, claim filing guidelines differ between payers. So, you’ll either want to follow up with the payer directly to see if the codes you included fit within their criteria or have a clearinghouse partner who already has all of the claim filing guidelines for the payers you work with on file.
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[@codeintherough]

I'm definitely interested in learning more about this as a pharmacy technician