Permissions

You will need Billing Permissions to see failed claims and fix them.

Before you Begin

This article is for Apex users only. 

Where are my rejected claims?

Rejected claims appear under the rejected tab under Billing > Claims > Rejected/Denied.

What is the Rejection Reason?

Rejection reasons are listed in the Claim Status Report. You can find this report under Billing > Claims > and the Submitted tab.
 
In the Claim Status Report .csv file, the reasons for Failed and Rejected claims are populated in the column. 

Failed Claim: An error was found in the claim by Apex. 

Rejected Claim: An error on the claim was reported by the insurance payer. For claim rejections, please reach out to the insurance payer with any questions about the rejection reason.

Here is a list of Common Failed Claims and how to fix them:

Invalid Payer ID

Failed Claim Reason: The payer address you are using has been marked as invalid in the Apex system. Please verify the address with the payer and correct the address.
Explanation: The Payer ID listed for this Insurer is incorrect.
How to Fix: 

  1. Look up the Apex Payer ID for the Insurer through the Apex Payer List.
  2.  Correct the Payer ID for the Insurer by following these instructions. 

Invalid CPT Code

Failed Claim Reason: CPT code is invalid.
Explanation: A claim has been submitted with an invalid CPT Code.
How to Fix: Correct the CPT Code for the claim by following these instructions.

Invalid Diagnosis Code

Failed Claim Reason: Diagnosis code requires further division.
Explanation
: A claim has been submitted with an invalid diagnostic code.
How to Fix:

  1. Go to the Client Profile, then select Notes.
  2. Navigate to the Initial Assessment & Diagnostic Codes tab.
  3. Remove All Signatures in order to edit the Initial Assessment. Only administrators can remove the signature from an Initial Assessment. 
  4. Correct the Diagnosis Code, then Save and E-Sign the Initial Assessment. 

Referring Provider Error

Failed Claim Reason: Expected value '1' for element 'NM102_EntityTypeQualifier' Loop 2310A - NM1*DN*6*9[referring provider value]*****XX*1609281542
Explanation
: Unnecessary information has been entered in the Referring Provider section of the client's Bill To & Insurance Info tab.
How to Fix

Unless the customer was referred by a different organization or clinician than the providers of your practice, this section should be left blank. 

  1. Go to the client's Bill To & Insurance Info.
  2. Scroll down to the Referring Provider section
  3. Remove the referring provider information.
  4. Save your work.  

Future Claim Date

Failed Claim Reason: Claim cannot be submitted with future date of service.
Explanation
: A claim has been submitted for a service date that has not occurred yet.
How to Fix

Claims cannot be submitted before the date of service. Resubmit the claim on or after the date of service.

Missing Client Signature

Failed Claim Reason: Patient Signature is Missing
Explanation
: The "Client authorized release of information necessary to process claims" option is marked as "Not Required" in the client's Bill To & Insurance Info tab.
How to Fix

"Client authorized release of information necessary to process claims" confirms that the client has given consent to release necessary information (like diagnosis codes and CPT codes) to the insurance payer in order to submit claims. 

Always have this option checked to "Yes".

  1. Go to the client's Bill To & Insurance Info 
  2. Scroll down to Manage Insurance and hit Edit
  3. Find the "Client authorized release of information necessary to process claims" option and check "Yes".
  4. Save your work.

Adjustments for Secondary Claims

Failed Claim Reason: Secondary Claim Information Missing or Invalid - Each line must balance; Line Charge Amount = Line sum of Adjustment Amts + Line Payer Paid Amt.
Explanation
: A secondary claim has been submitted without correct invoice adjustments.
How to Fix: 

In order to submit secondary claims you will need to explain how primary processed the claim. In TheraNest we do this with Adjustments. Payments + Adjustments must = the total amount billed of the invoice. 

Follow these instructions on how to enter Adjustments for secondary claims. 

If the primary insurance remitted $0 on the claim and the claim needs to be submitted to secondary insurance, please reach out to a TheraNest Billing Specialist.


Once the necessary information has been corrected, please resubmit the claim. 

Click here for instructions on how to resubmit a claim. 


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