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.
- Rejected claims contain one or more errors found before the claim is processed by the payer
- Rejected claims may be the result of a clerical error or invalid data
- Rejections usually come back as an EDI error message and will not show up on Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA)
- Claim rejection demands the understanding of EDI error messages by the medical biller
- Denials are explained on Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA)
- Most denied claims can be appealed for reprocessing which is time-consuming and expensive
- 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