Claim Rejections Claim Denials

Claim rejections and claim denials of insurance claims are among the major problems faced in the healthcare industry. The two terms are widely and more often used in the billing world.

Due to those misunderstanding, the overall revenue cycle can be irreversibly affected, and also, the errors can lead to have a bad impact, in addition to creating costly errors. Therefore, it is crucial to identify the terms and the difference between the terms clearly.

Claim Rejections

When the claims do not fulfill the specific requirements that should be completed for the claim, claim rejection is occurred by the insurance according to their guidelines given by the Centers for Medicare and Medicaid Services.

The rejected medical claims are unable to proceed by the insurance companies because the rejected claims are not computerized. The tenant is responsible for the claims only he receives, after the claim rejections, neither tenant get the claim, nor the claim is processed.

After the appropriate corrections are made, the claims can be resubmitted in this type of errors. Error can be a change in one digit of the patient’s ID and these types of errors can be corrected easily and quickly.

Claim Denials

claim denial

Denied claims are the claims that are preceded up to tenant, but payments halted due to a negative determination. This type of claim cannot be resubmitted, further researches should be made to identify the reasons for denying the claim. Then you can submit an appeal or reconsideration request. However, the claim remain unpaid until the final decision is made.

In case of resubmission with ought appealing; the claim is more likely to be denied considering it as a duplicate of previous claim. It will be just a waste of your time and cost.

Reasons for claim denial

Ardis Dee Hoven, MD, president of the AMA stated that the National Health Insurer Report Card is the cornerstone of an AMA campaign launched in June 2008 to lead the charge against administrative waste by improving the healthcare billing and payment system to Medical Economics. Further he stated that he campaign has produced noticeable progress by health insurers in response to the AMA’s call to improve the accuracy, efficiency and transparency of their claims processing.

claim rejection

American Medical Association’s National Health Insurer Report Card (NHIEC), which provides metrics on the timeliness, transparency and accuracy of claims processing of insurance companies, defines 5 major reasons for denied medical claims:

  1. Missing details – field left blank, incorrect plan codes, incorrect security number or missing security number etc.
  2. Duplicate claims- the same claim submitted twice or more with the same beneficiary, same date, same provider.

3.Already processed claims- The benefits for the claim are included in another service.

  1. Do not meet the coverage requirement of the payer- check the eligibility of the payer before submitting the claim.
  2. Expired time period- the claims should be reported tothe payer within given time period. Failure to submit on time may lead to deny the claim.

Improving Suggestions for Claim Rejections and Denial Rates

The steps can be taken to manage denials are:

  • Track and analyze trends in payer denials and rejections. By categorizing commonest causes for denials and rejections, a fast correction can be made.
  • Educate staff to handle rejections and denials quickly to achieve quick solutions.
  • Maintain regular audits to identify the weaknesses and problems in the documentation and apply appropriate corrective actions.
  • Discuss with the payer and revise or eliminate contract requirements that can lead to denials that are overturned on appeal
  • Automation of software will lead to optimize claim management, less errors and quick resolutions for the rejection and denials.
claim denial claim rejection

Claim Denial Vs. Claim Rejection



Denials and rejections are among the major issue for a physician’s practice as they can lead to a negative impact on practice revenue.

Educating the staff to collect and analyze claim data to determine trends in denials and rejections will lead to have quicker solutions for rejections and denials.

Proper interpretation of claims data can prevent rejections and denials before claims are submitted.

Automate your software’s to optimize your claim reimbursement, Greenway Prime Suite has one of the most advanced features to optimize and custom edits.  Such edits is used by top Revenue Cycle Management company and Medical Billing Service.


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