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  • Binta Patel

Top 13 Types of Medical Billing Rejections and How to Prevent Them



  1. Member Not Found: This occurs when the member's demographic data does not match the payer system. To prevent it, ensure that the member's data is accurate and up-to-date.

  2. Insured or Subscriber: Policy Canceled or Invalid Member ID Number for DOS: This rejection happens when the insurance policy on the claim is not eligible for the date of service billed. To avoid it, check the policy's validity before submitting the claim.

  3. Payor ID: This rejection occurs when the Payor ID on the claim is not valid. Double-check the Payor ID before submitting the claim.

  4. Payer Claim Control Number: This happens when the original claim control number for the corrected/adjusted/voided claim is missing. To prevent it, ensure that you include the correct claim control number.

  5. Referring Provider: This rejection happens when the referring provider's information is missing, invalid, or not credentialed with the payer. Check that the referring provider's information is accurate and up-to-date.

  6. ICD-10 Code: This rejection occurs when an invalid ICD-10 code is used. Verify that the ICD-10 code is correct and matches the diagnosis.

  7. COB Information Does Not Balance: This happens when the primary paid amount and all adjustments do not match the total charge on the claim. To prevent it, ensure that the COB information is accurate.

  8. Claim Submitted to Incorrect Payer: This occurs when the claim is submitted to the wrong payer ID. Check the insurance card for the correct payer ID before submitting the claim.

  9. Referring Provider NPI is Invalid: This rejection happens when the individual NPI number is incorrect. Verify that the NPI number is correct and edit it if necessary.

  10. Insured or Subscriber: Entity's Contract/Member Number: This occurs when the member ID or insurance card has an incorrect member ID. Double-check the member ID or insurance card to ensure that it is accurate.

  11. Missing MSP Info: This happens when the MSP type code is missing when Medicare is the secondary payer. To prevent it, include the MSP type code, such as MSP12 or MSP14.

  12. Address/City Missing/Invalid: This rejection occurs when the member's address or city is missing or invalid. Verify the member's address and city information.

  13. Procedure Code/Modifier Missing/Invalid: This happens when the billed CPT or modifier is missing or incorrect. Verify that the CPT and modifier are correct and match the payer guidelines.

Leave the Medical Billing hassles to the experts, and boost your revenue by 10-15%.

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