Rejections Vs. Denials: Do you know the difference?
guest post by TrinaW@integrity
Many people do not know the difference between an insurance denial and a rejection. This often causes frustration and confusion for the patients as well as the office staff who are on the receiving end of their phone calls. Despite the fact that these terms are often used interchangeably, they are in fact very different issues and require distinctly different courses of action to correct for processing.
In simplistic terms, a rejection means the electronic claim did not contain enough information or the correct information to actually make it through the edits of the clearinghouse and/or insurance company. Incorrect information could include: invalid or incorrect CPT, HCPCS or ICD10 codes, incorrect patient information such as insurance ID, date of birth, spelling of name, patient address, etc. In most cases, rejections are not something the patient will be aware of and they will not receive an EOB (explanation of benefits) on because their insurance company did not process the claim. In these instances, should the patient contact their insurance company to inquire about the particular date of service, they will inform the patient they have no record of the claim. Here is where you usually get that super fun phone call from the patient saying you failed to do your job and how much you suck. This same patient probably said their name was Franklin on their intake paperwork but failed to inform you that their insurance company has them listed as Collin.
Since data entry errors are frequently the cause of rejections, simply identifying, correcting and re-transmitting them should have your claim quickly on its way to being processed.
A non-covered claim is referred to as a denial. This is a claim that the insurance company did receive, process and formally deny payment on. The reasons for denials are vast and will be explained in the form of 2-4 digit alphanumeric codes with descriptions on the provider's remittance advice. Some common causes for denials are: no authorization for services provided, information requested from the provider or member was not received, services not considered medically necessary, no member coverage at time of service and coverage criteria not met. The reason for denial will determine your course of action. Some denials can be corrected and resubmitted rather easily while others will require a formal appeal with appropriate forms/documentation required by the particular insurance company. If you are unaware or unfamiliar with the explanation of a denial, give the provider customer service line a call.
Working rejections and denials in a timely manner is essential to maintaining cash flow and collecting all monies due to the provider. Noticing the same errors again and again? Take time to properly train and educate the appropriate staff members on the importance of accuracy in their job.