Manage Claim Rejections

When a claim is submitted electronically in the RCM, the system begins receiving status updates, also known as processing events, which provide additional context on the current state of the claim. While the payer receives many claims that are immediately accepted for adjudication, some claims are rejected because they do not meet one or more standards specified by the payer.

Managing these rejections is a crucial part of the revenue cycle, as it prevents charges from becoming bottlenecked. Let's review how to manage claim rejections in the RCM! 

• The Management Center is used to track and manage multiple aspects of the patient's journey. When a claim is rejected and sent back to the RCM, the system will automatically assign a follow-up date for the next day to bring it to the attention of an organization. These rejections can be tracked by locating and clicking the Claims Rejected - Pending Review tile in the Management Center.
  
• Claim rejections can be located and managed under the Work Center > Insurance Claims > Currently Held/Rejected Claims section of the RCM. To learn more about this section, click below.
  
• Once a claim has been submitted to the clearinghouse, it should begin receiving updates within 24-hours regarding its status; these messages are known as Processing Events. These processing events help users identify where the claim is in the submission process and whether a correction is required.
  

User Permissions

Organization Admins and Managing Organization Admins can manage claim rejections without additional permissions required. However, only Managing Organization Users can access this section of the Work Center and will require additional permissions to manage claim rejections. For additional information on user types and permissions, click here. 

Currently Rejected/Held Claims Overview

The Currently Rejected/Held Claims section of the RCM is located within the Work Center > Insurance Claims. It can display rejected, pending, and held claims when using the Insurance Payer Status filter.
 

Available Actions

• Clicking the Patient name will redirect the user to the Insurance Billing > Claims section of the patient's treatment episode.
  
• Clicking the Claim Control Number will direct the user to the Processing Events portion of the claim.
  
• Hovering over the Insurance Payer Status triggers the system to display the rejection response and additional details provided.
  
• Click Edit Payer Status to update the payer's status on the individual claim.
   
• Click Resubmit to generate the resubmission window for the claim. Please note this is not the same as generating a correction.
  
• The Bulk Edit Payer Status feature is available when selecting multiple claims simultaneously, enabling users to update the payer status of numerous claims at once.
  

Manage Claim Rejections

Once a claim has been submitted to the clearinghouse, it undergoes three checkpoints, or "edits," to ensure it complies with the payer's claim criteria. If it does not meet the requirements set by the payer, it will be rejected and returned to the RCM with a rejection message indicating the necessary changes. Once the rejection is received, the system will assign a follow-up date for the next business day to alert the organization of the rejection.

Workflow

Rejected claims can be removed by resubmitting the claim (or correction.) Additionally, manually updating the Payer Status will also remove the rejection for the Currently Rejected/Held Claims section of the RCM. Let's review how to update the Payer Status!

1. Navigate to Work Center > Insurance Claims > Currently Rejected/Held Claims.
   
2. Locate the claim rejection that you want to remove.
   
3. Click Edit Payer Status.
   
4. Update the Payer Status dropdown.
   
5. Finally, click Save to complete the process.
   

Available Payer Statuses

• • Accepted: Claims with this status will be removed after updating.
  • Canceled: Claims with this status will not be removed after updating.
  • Denied: Claims with this status will not be removed after updating.
  • Held By Payer: Claims with this status will be removed after updating.
  • Held By Pricer: Claims with this status will be removed after updating.
  • Name Matching: Claims with this status will be removed after the update is complete.
  • None: Claims with this status will be removed after the update is complete.
  • Pending: Claims with this status will be removed after the update is complete.
  • Rejected: Claims with this status will not be removed after updating.

Rejection Troubleshooting

Most rejections provide clear and concise information that allows users to identify the root cause of the rejection and correct it with ease. However, some rejections can be confusing and offer little to no information about the issue and what can be done to resolve it. Let's review how to troubleshoot rejections. 

• Our RCM Help Center features a section dedicated to common rejection messages and provides guidance on how to resolve them. If you are unable to find your specific rejection addressed in an article, please get in touch with [e-mail] for additional assistance. 
• If a rejection is received but provides no specific information as to why the claim was rejected, for example, "The claim has been rejected as unprocessable for invalid information." This rejection provides no specific information and, therefore, cannot be troubleshot in the RCM.
  
  These rejections will require a direct phone call to the payer's EDI department. When you call about the rejection, we highly recommend that you document the following information by creating a note within the claim: representative name, phone number called, and reference number provided. This information is required if the rejection requires further escalation.
• If you are unable to locate an article specifically about your rejection or need additional help with troubleshooting a rejection (and a call has already been made and documented to the payer), please reach out to our support team by phone or by email at [e-mail]. Our incredible team will be happy to assist in resolving the rejection.