Chapter 1: Rejected and Denied Claims Flashcards
What are the two biggest obstacles affecting the revenue cycle are?
Insurance Claim Rejections and Claim Denials.
Does insurance companies can process rejected insurance claims as they were never entered into their computer systems?
No.
Why do insurance companies can’t process rejected insurance claims as they were never entered into their computer systems?
Because they fail to meet specific data requirements.
Who can correct the errors that insurance companies can’t process and resubmit the claim?
Office Staff.
What is the first error that insurance companies can’t process?
Data entry errors (YYP4013 entered as YYP4103).
What is the second error that insurance companies can’t process?
Incorrect patient gender (hysterectomy submitted for a male patient).
What is the third error that insurance companies can’t process?
Patient is unidentifiable (Beth entered instead of Elizabeth).
What is the fourth error that insurance companies can’t process?
Missing information (date of birth)
What is the fifth error that insurance companies can’t process?
Invalid medical code.
Denied claims, were received and processed by?
The payer and a negative determination made.
Does a denied claim can be resubmitted?
No.
If the claim cannot be resubmitted what requires to be resubmitted?
The provider to file an appropriate appeal or request reconsideration form the payer.
Does some denials require the patient to make payments directly to the provider?
Yes.
What is the first reason for denied claims?
Patient not covered by the policy on the date of service.
What is the second reason for denied claims?
Procedure or service is not medically necessary.
