Missing Piece Blog

Claims: Rejections vs Denials

Submitting healthcare claims is a complex and ever-changing process as technology and regulations can sometimes seem like a moving target. Understanding claims processing is an evolving skill, but learning the basic language is the first step to successfully navigating this landscape.   

Claims Rejections 

Claims rejections occur when the clearinghouse or the payer stop a claim from entering their processing system. This is typically due to missing, incomplete, outdated, or incorrect information included in the claim. When claims fail to enter the payer’s processing system, providers do not receive an explanation of benefits or remittance advice for the rejection. Depending on the processor, providers may or may not receive a rejection notice from the clearinghouse or other electronic system.   

When the statuses of claims go unmonitored, rejections can pose an especially problematic effect for providers, their patients and patient’s families. It is not uncommon for providers to wait for a notification to trigger action on unpaid claims, naturally so, in the instance of a rejection that does not include a follow up notice, a significant amount of time may go by before realizing a claim went unreceived. At this point, deadlines for timely filing requirements may have passed for the payer. Unfortunately, timely filing denials are rarely overturned when appealed; therefore, it is very important that as part of a claims review process, providers have a method for monitoring rejections.   

Claims Denials 

Claims denials are claims that are received by the payer, processed, and then denied. Some of the more common reasons a claim might be denied include: 

  • Eligibility, coverage, or coordination of benefits issues  
  • Authorization problems  
  • Misinformation on the claim form 
  • Incomplete information on the claim form 
  • Incorrect or incomplete processing by the payer   

It is important to note that a claim that is processed by the payer and posted to a deductible or coinsurance is not considered a denied claim.   

When a claim denial takes place, providers may be notified of this in a few different ways including on explanation of benefits (EOB) documentation, explanation of payment (EOP) documentation, electronic remittance advice (ERA) and/or other methods by which providers are notified of claims payments and statuses. A denial response will typically include the reason for the denial. As a provider, you have a limited window of time — one that can vary significantly by payer — to respond to the denial and submit either a corrected claim or a new claim altogether. 

Following up on denied claims is an integral part of revenue cycle management. Many providers assume that once they submit a claim, their job is completed with a timely payment on the way (if only in a perfect world). An experienced Accounts Receivable representative is aware that follow up on claims submission is necessary to ensuring that payment is received.   

Does the pressure of claim follow up and accounts receivable management create stress for you? Let the experts at Missing Piece Billing and Consulting help you with your behavioral health and ABA billing needs. Our experienced staff knows and incorporates best practice payer specific policies and protocols on a daily basis to ensure that your claims are not rejected or denied, and that they are paid correctly and on time.  

Contact us today to schedule a free billing and revenue analysis at  

765-628-7400 or by email at weare@yourmissingpiece.com 

Be sure to follow us on LinkedIn and Facebook for the latest updates!