Clearinghouse rejections occur when claims are flagged for errors before reaching the payer. Common reasons include:
- Entity/Subscriber Not Found: Mismatch in patient or provider information.
- Invalid Medicare Member ID: Must be alphanumeric.
- Missing Claim Control Number: Segment REF is incomplete.
- Eligibility or Authorization Issues: Services not covered or pre-authorization not obtained.
- Coding Errors: Incorrect or missing CPT/ICD codes.
- Duplicate Claims: Previously submitted claims resent.
Solutions:
- Verify patient demographics and provider details (NPI, taxonomy code).
- Ensure Medicare IDs are correctly formatted.
- Enter the claim control number accurately.
- Check eligibility and secure authorizations.
- Review codes for accuracy and completeness.
- Avoid resubmitting claims unless corrected.
Healthcare providers and practice managers can reduce denials and speed up reimbursement by addressing these areas.