One common rejection reason used by the payer is that the "Member ID [is] Invalid for Date of Service. The goal of this article is to help the user identify these rejections and take the best next steps to obtain payment for these claims.
What is this rejection?
The Member ID Invalid for Date of Service Rejection is a payer rejection, meaning it is rejected by the payer after: a) the claim has been submitted to the clearinghouse b) the claim has passed first edits by the clearinghouse; and c) the clearinghouse has sent the claim to the payer.
Where will I see this rejection?
The rejection details will appear in the claim's Processing Events, once the claim has passed the clearinghouse's edits and has been reviewed by the payer.
The rejected claim will also appear in the Currently Rejected/Held Claims of an Organization's Work Center automatically.
The full details of the rejection will appear as follows:
Member ID Invalid for Date of Service (294), [X12 Info: 2010BA-NM109]
Why am I receiving this rejection?
This rejection is due to the member not having active coverage with the payer upon admission, not that there is no coverage for that date of service. This is a common source of confusion claims representatives, billers and patients alike.
Despite active coverage on the particular dates of service, the payer has reason to determine that there was no active coverage upon admission. The payer is within its rights to reject the claim(s) if there was truly no active coverage upon admission and the provider must prove that the payer is responsible for adjudicating the claim(s).
What do I do if I receive this rejection?
It is common for these rejected claims to languish in a practice's workflow because of the confusion that the rejection cause, and simply resubmitting the claim hoping it clears edits is a sure way to receive continued rejections.
Major payers advise that if you receive this rejection, the best course of action for a provider is to submit a written appeal consisting of:
- Paper copies of the rejected claim(s). Payers have system rules in place to reject electronic claims if the admission date is prior to the effective date, so the only way to get the claim in front of the payer is via paper claim.
- Supporting documentation, which will either be: a) that the patient did not have coverage under another plan upon admission; or b) the patient did have coverage under another plan but the plan was no longer processing claims by the date of admission.
Completing these steps as soon as possible is good RCM practice and using the rejection details provided by AveaOffice to inform your assignments and workflow will lead to better outcomes for your practice.