The most common claim rejections and how to fix them · Tips to avoid duplicate rejections or...

The most common claim rejectionsand how to fix them

Beth Ricket, EDI Operations Manager

Greenway Clearinghouse Services

3.2MCLAIMS

PROCESSED PER MONTH

98%PAYER

ACCEPTANCE RATE

4.1KCUSTOMER PRACTICES

>98% OVERALL

ACCEPTANCE RATE

$2.3BCLAIMS

VALIDATED PER MONTH

Most common rejections

• Duplicate claim.

• Eligibility.

• Payer ID missing or invalid.

• Billing provider NPI missing or invalid.

• Diagnosis code invalid or not effective on service date.

Duplicate claims

Submitting duplicate claims may result in delayed payment or identification as an abusive biller.

Common rejection descriptions

• Invalid; claim submitted previously –Intermediary

• Previously processed claim/line – Payer

• Duplicate claim – Payer

Tips to avoid duplicate rejections or denials

• Always check the status of a claim before resending.

• Check ERA for previously posted claim.

• Verify initial denial reason.

• Service appropriate to bill.

• Modifier requirement.

• Submit an appeal for denied claims, providing documentation with redetermination request.

• Do not resubmit claims while identical claim is pending.

• Do not resubmit entire claim when partial payment is made.

• Avoid automatic re-billing.

Eligibility

Using Greenway's eligibility feature can help verify the patient's information is correct, prior to their visit.

• Entity's contract/member number

• Subscriber and subscriber ID not found

• Entity not eligible for benefits for submitted dates

• Patient relationship to insured must be self (Medicare and Medicaid)

Tips to avoid eligibility rejections or denials

• Always ensure patient is accurate before or during registration/scheduling.

• Obtain copies of the patient's insurance card.

• Avoid data entry errors.

• Verify dates of eligibility.

• Verify benefit coverage.

• Obtain authorization when needed.

Payer ID missing or invalid

Visit Greenway's Customer Community to find the most up-to-date payer IDs.

Tips to avoid missing or invalid payer ID rejections

• Always make sure the correct payer ID is being used for the type of claim (Institutional vs. Professional vs. Dental).

• Include a secondary payer ID if secondary insurance is attached.

Billing provider missingor invalid

Make sure Greenway always has the most up-to-date tax ID and provider information for your practice.

• Submitter not approved for electronic claim submissions on behalf of this entity

• Entity's national provider identifier (NPI)

• Provider is not enrolled/approved for EDI claims with this payer

Tips to avoid billing provider missingor invalid rejections

• Confirm billing provider is credentialed with the payer(s).

• Confirm billing provider is credentialed with the clearinghouse to submit electronic claims.

• Confirm the correct NPI (group or individual) is credentialed.

• Confirm the correct tax ID is credentialed.

Diagnosis code

Ensure you’re using the most updated codes and coding at the highest level per procedure to get the most revenue per service.

Common rejection descriptions• Invalid or not effective on service date• Invalid diagnosis code or principal diagnosis

code• Must be valid ICD-10-CM diagnosis code• At least one other status code is required to

identify the related procedure code or diagnosis code

• Must be most specific• Must not be duplicate of another diagnosis

code on the claim for the payer

Tips to avoid diagnosis code missing or invalid rejections

• Validate the diagnosis is active for date of service.

• Validate the diagnosis is consistent with procedure being performed.

• Send ICD-10 diagnosis codes for dates 10/1/2015 to current.

• Code the diagnosis code to the highest level.

GREENWAY CLEARINGHOUSE SERVICES

Greenway Clearinghouse Services is the go-to clearinghouse helping Greenway Health customers

manage the full claim cycle by providing a holistic view of claim and financial data.

A new view into claims

• Enhanced validation and claim edits to improve clean claims.

• Holistic view into financial and claim data.

• Centralized portal with PM integration* for improved efficiency and workflow.

• Self-service tools to requeue and download claim reports and ERAs.

• Standardization of error messages, rejection descriptions, ERAs, and reports.

• ERA splitting across practices.

*Intergy customers only

Greenway Clearinghouse Services Portal

• Default Desktop

• Batch Management

• Claim Management

• Mailbox Management

• Client ERA Management

• Payers

• Task Management

Accessing the portal

From Intergy From a browser

• https://gcs.greenwayhealth.com -favorite this link!

• Works with Chrome, Firefox, Edge, IE 10 & 11.

Default desktopCustomizable home screen to show widgets most important to you.

Batch ManagementEasily reconcile claim batches with breakdowns of claim statuses and rejection reasons.

Claim ManagementSee and track each claim from the point of submission through payment.

Claim Management additional fields

View additional details, such as service lines with procedure and diagnosis codes, the adjudication summary, and referring and rendering providers.

Mailbox ManagementView and download inbound files, as well as re-queue claim reports and ERAs.

ERA ManagementAccess formatted EOBs to know what you billed, associated claims, and adjustments.

Payers ManagementFind the GCS Payer IDs and applicable enrollment instructions for each payer.

Task Management

Know which claims need to be reworked and assign them to appropriate users for corrections.

Sneak peek of upcoming dashboards

Request a call from a Greenway Health representative!

The most common claim rejections and how to fix them · Tips to avoid duplicate rejections or...

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