When you submit the insurance claim, there could be different outcomes in relation to claim processing and can be classed as Rejections (Claim Rejections, Insurance Rejections), and Claim denials or Denials. These outcomes appear on different stages of Claim processing and understanding of them can help resubmit the claim without any errors.

Claim Rejection

A Claim Rejection or Rejection is what you get when you first send out the claim and claim gets stuck in your scrubber or clearing house or you may get it through your clearing house or from your insurance company and it normally does not have the claim number, which basically means that claim could not be accepted/processed due to incorrect data and could not get into processing that much so that claim number can be issued.
For example, you send the claim through the clearing house, and then you get the clearing house report and on it has a rejection because you did not have the right date of birth, or it was not in the right format. This means, the claim did not leave the clearing house yet, it was rejected through the clearing house edits and that is why it was sent back.

Insurance Rejection

Another type of rejection where it has cleared from the clearing houses and hit the insurance but has not been adjudicated. This means, it has not been processed so it does not have the claim number. For example, the insurance company rejected the claim because provider NPI was not listed. But on the other hand, clearing house would not know about the provider NPI for the insurance company so it passes the clearing house. Not having the NPI listed could mean either during the Credentling that details was not correct/missing or provider was never enrolled with the payer.

Status With Insurance On Rejections

If your claim is rejected by the clearing house, now if you call the insurance company and ask about the claim they would not know about it because they have not dealt with it still as claim did not reach the insurance/payer. Another example could be that you did not include your members ID number (Your insurance company uses your policy number to track and process insurance claims and healthcare costs. Policy numbers may also be referred to as a subscriber ID or member ID number) or it was not correct so again the Edits the clearing house rejected it and if you do not pass edits, clearing house will reject it.
Also, sometime the clearing house edit reject the claim but it should not have been rejected. Let’s say a patient who was in hospital as an Inpatient. Normally you should have an admit date and a discharge date for an Inpatient. But sometimes you will not get the information from the provider and you do not have that. Firstly, you should try get any missing date from the provider but let’s say you could not get it and you have the admit date and do not have the discharge date. Now most clearing houses will not let you send the claim if you do not have both admit and discharge date but there are also clearing houses, they will let you override that Edit and then sometime insurance companies can still pay even if they do not have the discharge date. But if you do not know the discharge date, you will continue to have rejections from your clearing house unless your override it.

Claim Denials

This means claim has gone through, pass the clearing house, if any (normally in the case of electronic claims) and has been adjudicated. Once adjudicated, it means it has been processed, and it has a claim number and it comes back as denied. So basically insurance company has dealt with it but it has denied. For example you sent the claim, it went through your system and both clearing houses now hit the insurance company and it is denied because the ICD 10 code does not match the CPT code. Insurance has actually dealt with that claim but it was denied due to coding issues and you receive the ERA/EOB with claim number along ANSI (denial reason) codes.

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