Rejected and denied medical claims are both reasonably expected in the healthcare process. If you’re considering medical billing as a career, you’ll need to know the difference between the two.
A rejected medical claim and a denied medical claim sound synonymous with each other, right? You would think so! But the two are entirely different claims.
What are Rejected Claims?
A rejected medical claim typically has an error in it and is never processed or seen by the party that pays. The errors prevent insurance companies from paying and are sent back to the medical biller to correct.
Some of the common errors that lead to a rejected claim:
- Mismatched procedures
- Incorrect insurance numbers
- Incorrect ICD codes
- System coding issues
After the biller corrects the errors, the biller can resubmit the claim to the insurance company.
What are Denied Claims?
Denied medical claims are received and processed by an insurance company but deemed unpayable by the payer.
Common Reasons for Denials:
- The insurance company reviewed the claim and made a negative determination.
- The claim is missing information.
- The claim isn’t a necessary medical service.
- It’s for a service that isn’t covered by the insurance company.
Unlike a rejected claim, a medical biller cannot directly resubmit a denied medical claim.
To resubmit a denied claim, a medical biller must:
- Determine why the claim was denied
- Correct the claim if the claim contained an error
- Obtain an appeal or request for reconsideration
Time is of the essence when correcting and resubmitting a denied claim. Insurance companies allow a specified amount of time for resubmission; otherwise, the claim will remain unpaid.
Suppose a denied claim gets resubmitted without the proper appeal or request for reconsideration. In that case, it will get treated as a duplicate claim and denied.
Deal with Rejected or Denied Claims
As a medical biller, you’ll be working closely with these terms. It can be intimidating to start learning everything you need to know for a new career, but we can help! Our excellent medical billing course has everything you need to be a successful medical biller.