Skip to Main Content

Understanding Claim Rejections and How to Avoid Them

Date: 10/04/17

When a paper claim is submitted, it must first pass specific minimum edits to be accepted. Paper claims that don’t meet these minimum edits are considered invalid and are either rejected or denied.

Rejection vs Denial

It’s helpful to know the difference between a rejection and a denial. A rejection is defined as an unclean claim that contains missing or invalid data. Rejected claims are not entered into our claims adjudication system, and there is no Explanation of Payment (EOP) sent for these claims.

A denial occurs when the claim has passed the minimum edits and has been entered into our system for processing, but has been billed with invalid or inappropriate information that causes the claim to be denied. An EOP that identifies the denial reason will be sent.

You can avoid claim rejections by using this checklist as you prepare your paper claims:

  • Is the information readable?
  • Is the member’s date of birth, name and member ID number included?
  • Did you include the provider name, TIN or NPI?
  • Is the attending provider information included in Loop 2310A on Institutional claims when CLM05-1 (bill type) is 11, 12, 21, 22 or 72, or box 48 on the paper UB claim form?
  • Is the date of service prior to the date the claim was received?
  • Is the date of service or date span missing from the required fields?
  • Is the type of bill invalid?
  • Is the diagnosis code missing, invalid or incomplete?
  • Is the service line detail missing?
  • Is the date of service prior to the member’s effective date?
  • Is the admission type missing (Inpatient Facility Claims – UB-04, Field 14)?
  • Is the patient status missing (Inpatient Facility Claims – UB04, Field 17)?
  • Is the occurrence code/date missing or invalid?
  • Is the revenue code missing or invalid?
  • Is the CPT/Procedure code missing or invalid?
  • Was the correct form type used?

Making sure that all the required information is included, accurate and legible, and that the correct form was used, will go a long way toward ensuring timely processing of your claim and avoiding up-front rejections.

We also encourage you to participate in our Electronic Claims/Encounter Filing Program. If you’d like more information about filing claims with us electronically, call 1-800-225-2573 (Ext. 25525) or email EDIBA@centene.com.

Remember, you can also find helpful tips and information about claims and billing in our Provider Manual! And don’t forget – your dedicated Provider Consultant is available to assist you with identifying and correcting claims issues. For help connecting with your Provider Consultant, call Provider Services at 1-866-595-8133!