If you want your medical practice to get the right payments from insurers and patients, then you’ll need to be sure that medical billing is done correctly. When billing isn’t done properly, you can face either rejected or denied medical claims, but what is the difference between these two outcomes? Keep reading if you want to learn what’s different about denied medical claims and rejected medical claims.
About Denied Medical Claims
A denied medical claim occurs whenever an insurance company has gotten your claim and processed it, but they determine that it’s unpayable. Once a claim has been denied, the claims department will have the bill sent back to the policyholder, who will be given details regarding why their claim was denied in the first place.
There are many reasons why a medical claim could be denied. Some common reasons include:
- A claim error
- Missing referrals
- Lack of pre-authorization for treatment
- Credentialing or enrollment problems
- Submitting a claim too late
If a medical claim is denied, a patient will be able to submit an appeal or have a reconsideration request sent out. Keep in mind, however, that you’re not allowed to resubmit the exact same claim. If someone tries to do this, the new claim will be seen as a duplicate. This causes the new claim to get denied on the spot.
About Rejected Medical Claims
Rejected medical claims are a little bit different from denied ones. Unlike denied medical claims, which take place after an insurance company has completed processing them, rejected medical claims get back to the biller prior to having anything processed. This is mainly due to errors that the claims have. Some of these errors include the following:
- Clerical mistakes
- Patient data is not correct
- Information is missing
- Diagnosis and procedure code don’t match
From the perspective of a medical practice, rejected medical claims only serve to stagnate revenue. They don’t need an appeal to be resubmitted, however. Instead, all that has to be done is that the error(s) must be corrected. At that point, the medical claim will be able to continue on normally.
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