Claim may be getting rejected due to one of the following reasons:
1) Subscriber is ineligible
2) Subscriber's policy number is incorrectly entered
3) Claim is being submitted to incorrect payer ID
Reason 1:
(If available) run an eligibility check for the patient within CureMD to check for active coverage:
Open up patient's profile from patient module
Click on Registration > Profile
Click Insurance > Click on (E) or (P) in Blue
Click on Inquiry
Select Search Criteria as “Patient ID, Name & DOB” and click inquire
Also verify the patient's eligibility with the payer for the date of service being billed
Reason 2:
Verify the patient's policy number, name, gender, and DOB were submitted correctly on the claim and match the information shown on the patient’s insurance and identification cards.
Go to Patient > Registration > Profile > Demographics > Click on the Identification Card
Go to Patient > Registration > Profile > Insurance > Click on the Insurance Card
Reason 3:
Verify that the claim was submitted to the correct payer ID and cross reference the insurance name and payer ID listed on the patient’s insurance card.
Go to Patient > Registration > Profile > Insurance > Click on the Insurance Card
Go to Settings > Billing > Plan > Search Plan > Check Payer ID and Plan Name
Rejection Details
Claim may be getting rejected due to one of the following reasons:
1) Subscriber is ineligible
2) Subscriber's policy number is incorrectly entered
3) Claim is being submitted to incorrect payer ID
Resolution
Reason 1:
(If available) run an eligibility check for the patient within CureMD to check for active coverage:
Open up patient's profile from patient module
Click on Registration > Profile
Click Insurance > Click on (E) or (P) in Blue
Click on Inquiry
Select Search Criteria as “Patient ID, Name & DOB” and click inquire
Also verify the patient's eligibility with the payer for the date of service being billed
Reason 2:
Verify the patient's policy number, name, gender, and DOB were submitted correctly on the claim and match the information shown on the patient’s insurance and identification cards.
Go to Patient > Registration > Profile > Demographics > Click on the Identification Card
Go to Patient > Registration > Profile > Insurance > Click on the Insurance Card
Reason 3:
Verify that the claim was submitted to the correct payer ID and cross reference the insurance name and payer ID listed on the patient’s insurance card.
Go to Patient > Registration > Profile > Insurance > Click on the Insurance Card
Go to Settings > Billing > Plan > Search Plan > Check Payer ID and Plan Name
Rejection Details
Claim is getting rejected due to one of the following reasons:
1) Group NPI and rendering NPI is same. Individual NPI must be added in provider's profile instead of group NPI.
2) Rendering provider's NPI is invalid
3) Rendering Provider is not credentialed
4) On plan page in settings module, 'Not Allowed' is selected for Rendering Provider under Miscellaneous due to which Rendering Provider loop is not populating in EDI file.
Resolution
Use the following workflows according to the reasons:
Reason 1 & 2:
Go to Settings > Practice > Provider > Practice Provider
Click on Provider Name
Correct the NPI and save the profile page
Reason 3:
Kindly contact the relevant insurance and complete the credentialing process for the provider
Reason 4:
Go to Settings > Billing > Plan
Search the plan name and click on it
Click on Miscellaneous to expand the options
Select the "Rendering Provider" option as "Situational"
Save and resubmit the claim.
Rejection Details
Please contact the payer to review the billing rules: Specifically, find out from the payer if the procedure code/modifier combinations listed on the claims are allowed.
Note: CureMD Support does not provide coding assistance. Please contact your biller/coder with any CPT or ICD coding questions.
Resolution
Modifier and procedure combination is incorrect please correct the modifier and resubmit the claim. Kindly use the following workflow:
Patient > Charges > Click on appointment date
Correct the modifier and resubmit the claim
Rejection Details
This rejection indicates that the payer requires an accident date (Qualifier 439) and related cause for at least one of the diagnosis codes included on the claim. If there is a code between 800.00 – 999.99, V01.5, or 535.11, an injury or accident date are required for this payer.
Resolution
If there are any diagnosis codes used between 800.00 – 999.99, V01.5, or 535.11 then accident date must be used.
Kindly use the following workflow:
Patient > Clinical > Case Review
Click on Add > Select "Accident" as the Type
Scroll down to Accident Details
Select "AA. Auto Accident" as Condition Related to
Enter the Accident Date & Accident State and Save the case
Go back to the charge screen of the appointment date
Click on the double-arrows pointing downwards next to Insurance section
Select the Case from the Appointment section and save the charge
Rejection Details
This rejection indicates that the claim contains an NOC code, which is a "Not Otherwise Classified" code that requires a detailed text description in the SV1 01-7 segment of the service line for a professional claim or the SV2 02-7 of a UB claim.
Resolution
Kindly check if relevant description is added for these codes and resubmit the claim.
Use the following workflow:
Patient > Billing > Charges
Click on Appointment Date
Click on the Note icon next to Ordering Provider to Add the comments for non-specific codes
Save and resubmit claim
Rejection Details
This rejection indicates that the ordering (or referring provider) listed on the claim is the same as the rendering provider. Per this payer’s requirements, the ordering provider information should only be sent in the 2420E Loop (of the EDI file) if the service or supply was ordered by a provider who is different than the rendering provider sent in the 2310B Loop.
Resolution
Billing NPI should not be entered as ordering provider NPI in the application since these two cannot be the same. Either change the ordering provider NPI or remove it as per plan's requirement and resubmit the claim. Kindly use the following work flow:
Patient > Billing > Charges
Click on the Appointment Date
Change or remove the Ordering Provider's name from the selection
Rejection Details
This rejection indicates that the facility and billing NPI sent out on the claim are identical. Per ANSI 5010 requirements, the facility NPI should not be sent on the claim if it is the same as the billing NPI
Resolution
Billing NPI should not be entered as Location NPI in the application since these two cannot be the same. Either change the location NPI or remove it as per plan's requirement and resubmit the claim.
Kindly use the following work flow:
Settings > Practice > My Practice
Click on the Location name
Correct the Location NPI in the Location Settings section
Rejection Details
This rejection indicates that an invalid zip code for the payer is being sent on the claim. Please verify that the 9 digit zip codes submitted on the claim are valid for the payer’s Insurance Plan.
Note: Most payers require the full 9-digit zip code for addresses on electronic claims. This rejection typically indicates that the claim includes a zip code without the 4-digit extension. All addresses will need to be verified using the USPS Zip Code Look Up.
Resolution
Please verify the payer's address in the patient profile by using the following workflow:
Patient > Insurance > Click on plan name
Click on the Pencil Icon on Address section and correct the zip code
on Address section and correct the zip code