Claims Errors

• Clearinghouse Rejections
• Payer Rejections/Denials

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.

Payer Claim Denials

Claims that pass clearinghouse validation will be sent to the payer. The payer can deny or reject the claim for many reasons.

Common rejection/denial codes from insurance payers (there are too many to list them all here):

• Entity's National Provider Identifier (NPI)., Submitter not approved for electronic claim submissions on behalf of this entity. - Submitter - The claims enrollment has not yet been approved for the billing provider. The insurance payer will need to be contacted for an update on the status of the enrollment.
• Entity's National Provider Identifier (NPI)., Entity not found. Entity's National Provider Identifier (NPI). - Billing Provider - The NPI entered in Box 33 (Billing Provider) is incorrect and/or not found in the insurance payer's system. Most often there is a typo or the NPI 1 was used when the NPI 2 should have been used instead (or vice versa).
• Mbr not valid at DOS - The patient's coverage was not active for the date of service that is being billed.
• Duplicate Claim - The claim was previously submitted. This claim needs to be resubmitted with a resubmission code and original reference number.
• Eligibility Not Found - Either the patient's first name, last name, date of birth, or insurance ID do not match with what the insurance payer has on file. One (or multiple of them) will need to be corrected.
• Payment adjusted because this care may be covered by another payer per coordination of benefits - The insurance payer that the claim was submitted to has on their records that there is another insurance payer that is the primary insurance payer and they should be secondary. If there is another insurance payer, that insurance payer needs to be billed first. If the patient no longer is covered by the other insurance payer, the patient will need to reach out to the insurance payer that denied the claim to let them know.

Any claims rejected or denied by the insurance payer, will need to be resubmitted with a resubmission code. First, the correction will need to be made to the claim itself. Once the correction is made, go to Details > Other > Resubmission Information and select Edit. From here you can enter the resubmission code (use 7 or 8) and the original reference number. The original reference number is the payer claim number and can be found at the top of the claim details page.

Frequently asked questions

How do I know if the rejection is from the clearinghouse or the insurance payer?

If the rejection is from the clearinghouse, the status tab of the claim details page will specifically state that the rejection was from the clearinghouse (see image above). If the rejection is from the insurance payer, there will most likely be a payer claim number at the top of the claim details page (not all insurance payers send this information back to us, but most do).

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.