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Claim Rejection Types

Overview

Understanding rejection types is critical for reducing denial rates and improving revenue cycle performance. This document classifies all rejection types and provides guidance for prevention and resolution.

Rejection Classification

1. Administrative Rejections

Definition: Errors related to patient demographics, provider information, or claim metadata.

Common Causes: - Invalid member ID - Incorrect date of birth - Wrong provider NPI - Missing authorization number - Duplicate claim submission

Prevention: - Real-time eligibility verification - Front-end validation - Duplicate claim detection

Examples:

Code Description Resolution
A001 Invalid member ID Verify with payer
A002 Member not eligible on DOS Check coverage dates
A003 Provider not contracted Verify network status
A004 Duplicate claim Check prior submissions
A005 Missing authorization Obtain retro-auth

2. Clinical Rejections

Definition: Denials based on medical necessity, clinical appropriateness, or documentation.

Common Causes: - Insufficient documentation - Medical necessity not established - Experimental/investigational - Frequency limits exceeded - Clinical guidelines not met

Prevention: - Complete clinical documentation - Evidence-based protocols - Prior authorization compliance

Examples:

Code Description Resolution
C001 Medical necessity not met Submit clinical evidence
C002 Insufficient documentation Provide additional records
C003 Experimental procedure Clinical trial documentation
C004 Frequency limit exceeded Medical justification
C005 Not covered benefit Appeal with rationale

3. Eligibility Rejections

Definition: Denials related to coverage status, benefits, or policy terms.

Common Causes: - Coverage terminated - Pre-existing condition exclusion - Waiting period - Benefit exhausted - Out-of-network

Prevention: - Real-time eligibility check before service - Benefits verification - Network status confirmation

Examples:

Code Description Resolution
E001 Coverage terminated Verify with member
E002 Pre-existing exclusion Appeal with documentation
E003 Waiting period applies Check effective dates
E004 Annual benefit exceeded Patient responsibility
E005 Out-of-network Network exception request

4. Technical Rejections

Definition: Errors in claim format, FHIR validation, or system processing.

Common Causes: - Invalid FHIR bundle - Missing required fields - Schema validation failure - Encoding errors - Timeout/connectivity

Prevention: - Pre-submission validation - FHIR compliance testing - Retry mechanisms

Examples:

Code Description Resolution
T001 Invalid FHIR bundle Validate against schema
T002 Missing required field Complete all fields
T003 Invalid code system Use correct terminology
T004 Attachment error Re-upload documents
T005 System timeout Retry submission

5. Coding Rejections

Definition: Errors in diagnosis codes, procedure codes, or code combinations.

Common Causes: - Invalid ICD-10 code - Invalid CPT/HCPCS - Code not valid for DOS - Code combination invalid - Missing modifier

Prevention: - Code validation tools - Encoder software - Regular coder training

Examples:

Code Description Resolution
CO01 Invalid ICD-10 code Correct diagnosis code
CO02 Invalid CPT code Correct procedure code
CO03 Code not valid for DOS Use date-appropriate code
CO04 Unbundling detected Review CCI edits
CO05 Missing modifier Add appropriate modifier

6. Duplicate Rejections

Definition: Claims previously submitted or currently pending.

Common Causes: - Resubmission of paid claim - Multiple claim systems - Batch processing errors - Same service, same date

Prevention: - Claim tracking system - Duplicate detection - Submission logs

Rejection Analysis Framework

Root Cause Categories

pie title Rejection Distribution
    "Administrative" : 30
    "Clinical" : 25
    "Eligibility" : 20
    "Technical" : 10
    "Coding" : 10
    "Duplicate" : 5

Key Metrics

Metric Target Action Threshold
Overall Denial Rate < 5% > 8%
First-Pass Rate > 95% < 90%
Administrative Denials < 2% > 4%
Clinical Denials < 1.5% > 3%

Payer-Specific Patterns

Bupa Arabia

  • Strict prior authorization
  • Detailed clinical documentation
  • Frequent network checks

Tawuniya

  • Focus on coding accuracy
  • Timely filing critical
  • Package pricing rules

GlobeMed

  • TPA-specific forms
  • Pre-certification mandatory
  • Utilization review focus

ClaimLinc Rejection Analysis

BrainSAIT's ClaimLinc agent provides:

  1. Automated Classification - AI-powered rejection categorization
  2. Root Cause Analysis - Pattern identification
  3. SAR Loss Estimation - Financial impact calculation
  4. Resubmission Guidance - Corrective action recommendations
  5. Trend Reporting - Denial pattern insights

Last updated: January 2025