Claim Rejections and Denials

Claim rejections and denials are major pain points for any medical practice as these are directly related to revenue and cash flow. Often times the two terms are used interchangeably, however, claim rejection and denials are not the same. Despite the similarities, this minor misunderstanding can create major errors and can have a negative impact on the overall revenue cycle. 


Rejected claims cannot be processed by the insurance companies because they were actually never received nor were they entered into their computer systems. If the payer didn’t receive the claims, it cannot be processed. However, this type of claim can be resubmitted as soon as the errors are made correct. Some of the errors are easier to fix than others.


Denied claims are different because they are defined as claims that were processed and a negative decision was made. This type of claim can be resubmitted as a corrected claim to avoid a duplicate denial, or based on the denial reason you may only have the option to appeal or send back for reconsideration. If the claim is resubmitted without an appeal or reconsideration request it will most likely be denied as a duplicate.


According to the American Medical Association’s National Health Insurer Report Card (NHIEC), there are 5 major reasons for denied medical claims:


  • Missing information- examples include even one field left blank, missing modifiers, wrong plan codes, incorrect or missing social security number

  • Duplicate claim for service- when claims are submitted more than once for the same service provided, same beneficiary, same date, same provider, and single encounter

  • Service is already adjudicated- (unbundling) services. Benefits for a service are included within another service or procedure

  • Services not covered by payer- before providing services, check details of eligibility or call payer to determine coverage requirements

  • The limit for filing has expired- there are a set number of days following service for a claim to be reported to the payer. If outside of that time period, the claim will be denied. Included in this period is time to rework rejections


If a practice properly interprets claims data, pays attention to the details and takes a proactive approach, it is possible to prevent rejections and denials before claims are submitted. EMMG offers a comprehensive suite of custom services covering all aspects of billing, collections and revenue cycle management. Because of our vast experience in physician billing and working with practices in virtually all medical specialties, we typically review and evaluate the current list of billable procedures to develop a tailored solution to help avoid claim rejections and denials. 


EMMG’s services are tailored to meet and exceed billing needs and allow clinicians and their staff to focus solely on the delivery of outstanding care. If you are interested in getting a custom billing plan in place for your practice or hospital, contact EMMG today!

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