Claim Issues: How to Fix the Top Rejection Codes

Claims rejections can be frustrating, but understanding the common rejection codes and their resolutions can save time and effort. Here are the top six rejection codes and how to address them effectively:

1. Code 21 - INVALID PATIENT/SUBSCRIBER INFORMATION

• Issue: The claim contains incorrect or incomplete patient or subscriber details.
• Solution:
  1. Double-check the patient’s first and last name, date of birth, and insurance ID number.
  2. Confirm the subscriber relationship to the patient (e.g., self, spouse, dependent).
  3. Double-check the subscriber's first and last name and date of birth.
  4. Resubmit the claim with corrected information.

2. ERA Denial - Expenses Incurred After Coverage Terminated

• Issue: The claim is for services provided after the patient’s insurance coverage ended.
• Solution:
  1. Verify the patient's coverage period with the insurance provider.
  2. Ensure the date of service falls within the coverage period.
  3. Contact the patient for updated insurance information if the coverage has changed.

3. ERA Denial - Missing/Incomplete/Invalid Place of Service

• Issue: The place of service (POS) code is either missing or incorrect or requires a modifier.
• Solution:
  1. Review the POS code in the claim. Common codes include:
     • 02: Telehealth services provided other than in patient's home
     • 10: Telehealth services provided in patient's home
     • 11: Office
     • 99: Other place of service
  2. Match the POS code with the service location on the claim.
  3. Update the claim with the correct place of service code and/or modifier and resubmit.

To update the place of service or add or edit the modifier, follow the instructions below:

If the claim is already marked as Needs Reviewed, Rejected, or Denied: Open up the claim and go to the Details tab > Services. Click the three dots on the right hand side in the date of service row and select Edit. In the pop up window, correct the location and/or modifier and then save. Next, copy the payer claim number from the top of the page and navigate to the Details tab > Other > Resubmission Information > Edit. Select resubmission code 7 and paste the payer claim number in for the original reference number, then save. Now you can scroll to the top and click Submit.

If the claim's current status is Processed: Open up the claim, click the three dots in the top right hand corner and select Reopen for Edits. In the pop up window select yes, you do plan to resubmit the claim to the insurance payer. The payer claim number should populate and then select Reopen. Now go to the Details tab > Services, click the three dots on the right hand side in the date of service row and select Edit. In the pop up window, correct the location and/or modifier and save. Then scroll to the top and click Submit.

4. ERA Denial - Missing Procedure Modifier(s)

• Issue: Procedure modifiers that provide additional details are missing or incorrect.
• Solution:
  1. Identify if the procedure requires a modifier (e.g., 95 or GT for telehealth).
  2. Refer to the payer’s guidelines to determine which modifiers are acceptable.
  3. Add or edit the appropriate modifier(s) and resubmit the claim.

To add or edit the modifier, follow the instructions below:

If the claim is already marked as Needs Reviewed, Rejected, or Denied: Open up the claim and go to the Details tab > Services. Click the three dots on the right hand side in the date of service row and select Edit. In the pop up window, either select Add Modifier or replace the current modifier and then save. Next, copy the payer claim number from the top of the page and navigate to the Details tab > Other > Resubmission Information > Edit. Select resubmission code 7 and paste the payer claim number in for the original reference number, then save. Now you can scroll to the top and click Submit.

If the claim's current status is Processed: Open up the claim, click the three dots in the top right hand corner and select Reopen for Edits. In the pop up window select yes, you do plan to resubmit the claim to the insurance payer. The payer claim number should populate and then select Reopen. Now go to the Details tab > Services, click the three dots on the right hand side in the date of service row and select Edit. In the pop up window, either add the modifier or replace the current modifier with the correct one and save. Then scroll to the top and click Submit.

General Best Practices:

• Stay Updated on Guidelines: Regularly review updates to ICD-10, CPT, and payer-specific policies.
• Collaborate with Payers: Contact the payer for clarification on unclear rejections.
• Train Staff: Ensure billing staff is well-versed in coding and payer requirements.

By addressing these common rejection codes with diligence, you can improve claim acceptance rates and reduce revenue delays.