Insurance claim rejections and its followup
- Invalid member name, date of birth or identification number
- Policy canceled or coverage terminated
- Invalid or obsolete ICD 10 diagnosis code
- Non specific ICD code posted for CPT 93306
- External cause code cannot be used as Principal Diagnosis code
- Relationship to insured must be 18 – Self for Medicare
- The payer has received the exact claim or service before
- Hospitalization date missing or invalid
- Date of service invalid
- Subscriber Postal/Zip code invalid
Invalid member name, date of birth or identification number
Rejection from various insurances
- Medicare – ACK/REJECT INVAL INFO – Entity’s contract/member number. Usage: This code requires use of an Entity Code. – Insured or Subscriber
- Aetna – ACK/RETURNED – Subscriber and subscriber id not found.
- BCBS – ACK/REJECT INVAL INFO – Subscriber and subscriber id not found.
- Humana – Category: Acknowledgement/Returned as unprocessable claim The Claim/Encounter has been rejected and has not been entered into the adjudication system Status: Entity not found Entity: Patient
- Ambetter – SUBSCRIBER/MEMBER ID NOT FOUND // 02 – Invalid Mbr.
How to avoid the future rejection : ABC’s Medical biller will make sure the member name, Date of birth and the member identification number are matching the insurance card before submitting the claims to the health insurance
How to fix rejection : ABC’s medical billing specialists will compare the member ID, date of birth and member name is matching correctly in the insurance card. If the insurance card is not found, the medical biller will check the patient demographics in the hospital portal. If both of them failed the insurance biller will call the patient to get the correct information
Policy canceled or coverage terminated
Rejection from various insurances
- Cigna – ACK/REJECT INVAL INFO – Entity not eligible for benefits for submitted dates of service. Usage: This code requires use of an Entity Code. – Patient
- Medicare – SUBSCRIBER AND/OR SUBSCRIBER ID IS NOT ELIGIBLE FOR SUBMITTED DATES OF SERVICE. VERIFY THE SUBSCRIBER INFORMATION ON THE CLAIM MATCHES THE ID CARD EXACTLY.
- Humana – Category: Acknowledgement/Returned as unprocessable claim The Claim/Encounter has been rejected and has not been entered into the adjudication system Status: Policy canceled
- Ambetter – NO MEDICAL COVERAGE EFFECTIVE FOR DATE OF SERVICE // 09 – Mbr not valid at DOS
- Aetna – ACK/RETURNED – Policy canceled. – Insured or Subscriber
How to avoid the future rejection : ABC’s medical biller should make sure if the patient has active coverage before submitting the claims to the health insurance. Before providing healthcare services to the patient, the front desk or physician has to get the updated information from patients.
How to fix rejection : ABC’s medical billing specialists will confirm if the patient is eligible in the current insurance portal. If the patient is not eligible the medical biller will check if any other insurance available in the patient documents or in the hospital portal. If no other insurances are found the medical biller will check if Medicare (if the patient is older than 65 years) and Medicaid are eligible. If all the above failed the insurance biller will bill the patient.
Invalid or obsolete ICD 10 diagnosis code
Rejection from various insurances
- UHC – H51082 ICD-10 code ‘I482’ must be coded to the highest specificity//ACK/REJECT INVAL INFO – Diagnosis code.
- BCBS – Svc: The ICD10 Diagnosis Code I482 was not valid on date 20191218 in code table ICD10 Diagnostics. Invalid Data: 20191218-20191218
How to avoid the future rejection : ABC’s medical biller should make sure the ICD diagnosis code is not obsolete for the DOS.
How to fix rejection : ABC’s medical billing specialists will analyse and find the valid and appropriate ICD10 diagnosis code. In this case the claim has the ICD 10 diagnosis I48.2 (Chronic atrial fibrillation) which is a obsolete code since 10/01/2019 and the replacement codes are I48.20 (Chronic atrial fibrillation, unspecified) and I48.21 (Permanent atrial fibrillation). The medical coder has to make sure the ICD 10 diagnosis is not obsolete and it supports the service rendered. Also medical billing coder will inform the physician/practice not to use the obsolete code ICD10 diagnosis in future
Non specific ICD code posted for CPT 93306
Medicare error: SMARTEDIT LBI PER LCD OR NCD GUIDELINES PROCEDURE CODE 93306 HAS NOT MET THE ASSOCIATED DIAGNOSIS CODE RELATIONSHIP CRITERIA FOR CMS ID(S) L37379.
How to avoid the future rejection : ABC’s medical biller should make sure the ICD code is specific for CPT 93306 before submitting the claims to the health insurance
How to fix rejection : ABC’s coding specialists will check if the ICD code is compatible with the CPT 93306 according to LCD/NCD guidelines. The insurance biller will communicate with the provider and obtain the appropriate ICD code before submitting the claims to the health insurance.
External cause code cannot be used as Principal Diagnosis code
Rejection from various insurances
- Tricare East : External cause code cannot be used as Principal Diagnosis code. Value of sub-element HI01-02 is incorrect. External cause code cannot be used as Principal Diagnosis code. (W57XXXA) (TRI)
- BCBS error : External cause code cannot be used as Principal Diagnosis code. Value of sub-element HI01-02 is incorrect. External cause code cannot be used as Principal Diagnosis code. (W57XXXA) (BLU)
- Wellcare error : External cause code cannot be used as Principal Diagnosis code. Value of sub-element HI01-02 is incorrect. External cause code cannot be used as Principal Diagnosis code. (Y048XXA) (WEL)
How to avoid the future rejection : ABC’s medical biller will make sure not to add the external cause code(Injuries Due to Falls and Exposure, Transport Accidents, Self-Harm, Assault,etc,.) as primary diagnosis.
How to fix rejection : ABC’s medical billing specialists will check if the external cause diagnosis code is added as primary diagnosis. If it is added, then the medical biller will switch the external cause diagnosis code from primary and replace it with another appropriate diagnosis on the claim. If the external cause diagnosis is the only diagnosis exists on the claim the insurance biller will communicate with the provider to obtain the correct primary diagnosis.
Relationship to insured must be 18 - Self for Medicare
Medicare : Relationship to Insured must be 18 – Self for Medicare. 2000B.SBR*02 (GEO)
How to avoid the future rejection : Medicare requires the patient relationship to the insured as self. ABC’s medical billers should make sure to select the patient relationship to insured as self for all Medicare primary patients before submitting a claim.
How to fix rejection : ABC’s medical billing specialists make sure the patient relationship is insured is self before submitting the claim.
The payer has received the exact claim or service before
Humana rejection : Acknowledgement/Returned as unprocessable claim The Claim/Encounter has been rejected and has not been entered into the adjudication system Status: Duplicate of a previously processed claim/line
How to avoid the future rejection : Most of the time the claim is submitted more than once because of system and network issues. ABC’s medical biller will check the payer portal and clearing house reports before submitting those claims again.
How to fix rejection : In some cases if Humana is denying the claim as duplicate there is a chance that the claim was re-submitted without any edit after the first denial. In such cases the insurance biller will check if the submission reason code 7(Replacement of prior claim) and resubmission reference number (Payer control number) are updated in header notes of the claim. Also check if the claim has been submitted more than once in a day.
Rejection from other insurances
Medicare : Duplicate Claim: Invalid; Claim submitted previously
UHC : Duplicate Claim: Invalid; Claim submitted previously
BCBS : Duplicate Claim: Invalid; Claim submitted previously
Aetna : Duplicate Claim: Invalid; Claim submitted previously
How to fix rejection : ABC’s medical billing specialists will check if the claim has been submitted more than once in a day and this rejection will not affect the status of the initial claim submission.
Hospitalization date missing or invalid
Rejection: (E_V) SendBusComponents.ClaimFormatValidator (8,0765) Must have hospitalization start date if place of service code is 21 (Inpatient Hospital)
How to avoid the future rejection : ABC’s medical biller should make sure to add the hospitalization from and to date if the POS is 21 before submitting the claims.
How to fix rejection : ABC’s medical billing specialists will add the hospitalization date to the encounter or to the case.
Date of service invalid
Rejection: (E_V) SendBusComponents.ClaimFormatValidator (8,0080) Date of Service From and To dates are invalid. Your claims cannot be submitted because the Date of Service From date is after the Date of Service To date.
How to avoid the future rejection : In some cases the year, month or date might have mistyped. ABC’s medical biller will make sure to enter the correct date of service before submitting the claims to the health insurance
How to fix rejection : ABC’s medical billing specialists will check if the date/month/year entered in the encounter correctly. If the date of service is entered incorrectly, the insurance biller will correct the date of service from and to date in the encounter.
Subscriber Postal/Zip code invalid
Rejection: (E_V) SendBusComponents.ClaimFormatValidator (8,0038) Patient zip code not valid: [30296 343] Your claims cannot be submitted without a valid patient address.
How to avoid the future rejection : ABC’s medical biller will make sure to add the full 9-digit ZIP code for addresses on electronic claims.
How to fix rejection : ABC’s medical billing specialists will check and add the correct 9-digit ZIP code in the patient address.