Rejections vs denials

Insurance claim denials and rejections are one of the biggest obstacles affecting healthcare reimbursements.

A claim rejection occurs prior to claim processed by payer and is typically related to input errors or invalid data. A denied claim is processed by the payer and determined as unpayable. In both instances, the payer will return a notification for the reason of rejection or denial.

Rejections:

  1. Rejected claims contain one or more errors found before the claim is processed by the payer
  2. Rejected claims may be the result of a clerical error or invalid data
  3. Rejections usually come back as an EDI error message and will not show up on Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA)
  4. Claim rejection demands the understanding of EDI error messages by the medical biller

Denials:

  1. Denials are explained on Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA)
  2. Most denied claims can be appealed for reprocessing which is time-consuming and expensive 
  3. If a denied claim is resubmitted without an appeal or reconsideration request it will be most likely considered as duplicate and will remain unpaid, costing the practice time and money

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