Claim Issues: Errors
Clearinghouse Rejections
Claims can be rejected by the clearinghouse when required information is either missing, inaccurate or formatted incorrectly. If the clearinghouse rejects the claim, the Status tab message will indicate that is was rejected by the clearinghouse and the reason why.
Common rejection codes from the clearinghouse:
- Diagnosis Code Invalid [F42] (or other diagnosis codes such as [F431, F33, F112, F32, F101, F90]) - This diagnosis code is a valid, but non-billable diagnosis code. The insurance payer wants the diagnosis to be to the highest level of specificity (for example, F42.2, F42.3, F42.4, F42.8 or F42.9) or the insurance payer does not cover services for the diagnosis code. The diagnosis code will need to be adjusted before this claim can be accepted.
- Invalid Modifier [95] - The insurance provider does not accept claims for services provided with that particular modifier. Most insurers use modifier 95 with place of service codes 02 or 10, while others use GT or no modifier at all. Additionally, if the place of service is listed as 11 and has modifier 95, the clearinghouse cannot forward this claim to the insurer. The modifier needs to be removed or corrected before the claim can be accepted.
- Invalid frequency code [6] - When resubmitting claims to the insurance payer that they have previously denied, most payers require claim resubmission codes 7 or 8 to be used. The resubmission code will need to be changed in the claim before this claim can be accepted.
- Diagnosis [F438] (or any other diagnosis code) is valid, but not for this date [insert date of service] - This diagnosis code is no longer a billable diagnosis code. The diagnosis code will need to be adjusted before this claim can be accepted.
Any claims rejected by the clearinghouse do not need to be resubmitted with a resubmission code nor does the claim need to be deleted. The information can be corrected in the claim itself and then the claim can be submitted again to the clearinghouse.
Frequently asked questions
How do I resubmit my denied or rejected claims?
See our article on Rejections and Denials for information about how to resubmit claims that have been rejected or denied.
How do I know when a claim gets rejected or denied?
The Daily Digest notifies Sessions Health customers of several different important events. Any time we receive information from the clearinghouse that you have denied or rejected claims that need to be reviewed, you will receive a notification in your Daily Digest. Additionally, rejected or denied claims will be in the Needs Attention area of the Home Page.