Fixing Most Common Claim Rejections
Fixing claim rejections is not difficult once you know the reasons behind it. Note that since each payer/clearinghouse words the rejection message differently, there may be multiple messages listed for one entry.
Payer ID Missing or Invalid
This rejection is stating that the payer ID that was used on the claim is not valid for electronic claims submission. To be able to send claims through a clearinghouse, an electronic connection has to be made between the payer and clearinghouse. While each payer has its own unique payer ID, there are instances when the clearinghouse has a payer ID for that payer that differs from the ID the payer uses. In these instances, claims should be submitted using the clearinghouse payer ID. The clearinghouse will forward the claims to the payer using an outbound payer ID.
Subscriber Zip Code is Missing or Invalid
This rejection indicates that an invalid ZIP code is being sent on the claim. Most payers require the full 9-digit ZIP code for addresses on electronic claims. This rejection typically indicates that the claim includes a ZIP code without the 4-digit extension. For zip code verification, please utilize the zip code search tool provided by the United States Postal Service at Zip Code Lookup. When all corrective actions are completed, rebill and resubmit all affected claims.
Invalid Subscriber Primary Identifier
This rejection has three possible causes:
- The claim was submitted to the wrong payer ID. This is the most likely cause if this rejection was received on claims for multiple patients.
- The patient’s demographics or insurance policy included on the claim was not eligible for the date of service billed.
- The patient is a new born or recently added to the guarantor’s insurance policy.
Resolution steps will vary depending on the cause:
- If the claim is submitted to the wrong payer ID, verify and edit the payer ID.
- If the patient demographics or policy is incorrect, verify the patient’s eligibility.
- If the patient is a new born or recently added to the guarantor’s insurance policy, you can contact the payer to verify the patient is active under the insured’s policy.
When all corrective actions are completed, rebill and resubmit all affected claims.
Billing Provider NPI Missing or Invalid
This error is most likely due to submitting a claim with the wrong billing NPI. Most payers have your NPI that you shared with them at some point on file. When they receive a claim, they look up the NPI in their system to see if they have the billing NPI on file. If they do not have it on file, then they will reject the claim. In addition to the NPI, they also have your Tax ID on file. Therefore, this error could also be referring to a claim submitted with the wrong Tax ID reported in (the equivalent of) Box 25 on the claim. You should always submit claims to the payer using the same NPI and Tax ID that the payer has on file for you.
Diagnosis Code Invalid
Each year new, changed and deleted diagnosis codes are released and become effective or deactivated on October 1. To avoid this rejection, validate the diagnosis is active for the date of service. Also, cross-check that the diagnosis is consistent with the procedure being performed. Make sure you are coding the diagnosis code to the highest level. Also, make sure you are sending ICD-10 diagnosis codes for dates 10/1/2015 to current.
Fixing claim rejections is a crucial process but it consumes a lot of time. E2E Medical Billing Services can help you to reduce claim rejections and submit clean claims. To know more about our basic medical billing services, call us at 888-552-1290 or write to us at [email protected]