Rejection: When insurance company denies a claim stating that info provided in the claim is not sufficient to process the claim, for which the pt or the guarantor is responsible (which can be collected only form them) is called the “REJECTION BY INS” e.g., incorrect ins ID#, SS#, Wrong ins, deductible etc are the some of the e.g. for rejection.
Review: When insurance company denies a claim stating that the it needs additional info for processing, which can be obtained from the provider’s or billing office can be defined as “REVIEW”. Invalid provider, wrong procedure or diag code, invalid info on claim, incomplete info on claim etc are some of the e.g. for a “REVIEW”.
Insurer denial/rejection code and descriptions are usually outlined on a form, which looks very similar to their payment voucher, the explanation of benefit form. When a carrier identifies a specific reason for non-payment of a medical service/procedure forwarded for reimbursement, it becomes the responsibility of the medical biller to review and research the problem identified by the carrier, resolve the issue and resubmit the service/procedure rendered by the provider. This is what “REVIEW” is all about.
Listed below is a listing of frequent “statements” used by insurance companies;
- Suspect for other health care coverage-additional information has been requested from the patient....
- Provider license number is either missing, incorrect or the name identified does not correspond to the reported number.
- The procedure listed does not correspond to the location of service reported
- Submitted claim has exceeded time filing limit.
- Date of service listed is a duplicate of a claim previously paid.
- Procedure invalid to date of service.
- Payment for this service is included in the payment for a related service performed on the same day.
- This service/procedure is not payable for the diagnosis reported
- Your claim cannot be processed as submitted, there is not tax ID number listed.
If we find the above statements these are usually reviewed as they can be researched and resolved in the Medical Billing office itself.
- The policy specified for this patient/subscriber was not in effect for the specified date of service.
- The personal information for this patient does not match the insurer enrollment file.
- This service is not a contract benefit when it is related to a routine physical
- Annual Deductible not met.
- Additional information required from patient.
- Copy of ID card required to identify the insured as the member
Under these situations it is advisable to reject them and transfer the claim to secondary insurance or self-pay.
Note: Though we can differentiate review and rejection by the above definition, care should be taken to use them, and situation should be analysed correctly (based on EOB) before final decision is taken if we have to review or reject a claim.
General reasons for Rejections and Reviews.
The claim will be denied if the patient’s coverage is not effective at the time of the service. The coverage may have terminated before the date of the patient’s service.
The claim will be denied if the coverage is secondary to the patient.
The claim will be denied if the insurance company is unable to identify the patient in their records. This could be due to incorrect policy identification number or an incorrect policyholder’s name.
The claim will be denied if it is sent past the filing limit. All insurance companies have a filing limit counted from the date of service. In this cases charge will either be adjusted off or written off. If the billing office can show the insurance company a proof of previous filing, the denial will be reconsidered.
Some insurance companies have specific procedures that their policies do not cover. If a charge is denied as a non-covered service, the patient can be billed.
A claim can be denied if there is any information missing or incorrect on the claim like the provider#, patient’s address group# etc.
A claim can be put on hold or denied if the insurance company requires information from the patient.
An insurance company may deny a claim stating that the procedure performed does not match the diagnosis.
Some insurance company which requires a pre-certification or a referral for the treatment performed will deny the claim or make a low payment if these are not attached to the claim or if the claim does not contain the pre-certification or referral#.
An insurance company may deny a claim stating that the service is inclusive in another code or when multiple units of the same code are billed. In these cases, the insurance is questioning the utilization of one code, when another code. Here the billing office can review the claim by sending additional information like the doctor’s notes, reports or operative notes which prove that the patient’s condition demanded these additional services or units.
In the case of a managed care network where a patient’s policy states that he can only see specific physicians, if the rendering physician is not a part of the network, the claim will be denied stating that the patient went out of network.
When more than one unit of a service is performed in a day, the insurance may pay only one unit and deny the rest as duplicates.
Some insurance coverage has a limit on the payable benefits per year. For e.g., if a policy covers all charges up to $10,000 for a calendar year, the patient is responsible for all charges after the insurance has paid the $10,000. When the insurance has met its maximum, it will deny the claim stating that the maximum benefits have been met.