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Rejections vs. Denials of Health Insurance Claims


Medical billing jobs demand accuracy of the highest levels and however efficient a medical biller maybe, there would be instances where rejections and denials of medical claims come across. For a layman, both rejection and denial may appear similar. But, in the real sense, there is a huge difference in them and it is utmost important for the medical billing professionals to understand the difference between rejections and denials in order to adopt the appropriate remedial for the ruling of rejection or denial. A good understanding of this difference brings in timely reimbursements for the services provided by the healthcare provider, thereby, increasing the profitability of the organization. 

Medical claims that are submitted to the insurance payer but fail to meet certain specified requirements are rejected. In the medical billing field, these are called rejections. The rejection of the claim may be a result of not meeting specific data requirements or not meeting basic format that is required to be followed for insurance claims. Rejected claims are not processed as they are not considered to be received by the insurance payer. A rejected claim can be resubmitted after rectifying the error that is the reason for the rejection.

A denial is an altogether different issue from rejection. Denials are those medical claims that are received by the insurance payer but a negative decision is taken regarding the payment. It means the claim is processed by the payer, but, payment is denied. In such cases, it has to be ascertained as to why the claim was denied. Once, the reason for denial is determined a reconsideration request or an appeal has to be submitted for considering the claim again.

Reasons for Denials:
Identifying the reason for rejection and resubmitting the claim is much simpler than a denial case. Let us understand why claims are denied.

  • Information is missing: Any missing information, any missing code or incorrect code, any wrong information or missing information regarding the social security number may lead to the claim denial.
  • Duplicate claim: If the claim is a duplicate claim, then it is denied.
  • Settled claim: If the services mentioned in the claim are already settled, like in the case of unbundling charges.
  • Services not covered: The services that are charged in the claim may not be covered by the insurer, hence denied.
  • Filing time: Insurer payers require that the claims are submitted within a time limit for the services provided. If this time limit is not met and claims are submitted beyond the stipulated time, then the claim is denied.

Rejections and denials are an inevitable part of medical billing jobs and a thorough understanding of these is mandatory to minimize rejections and denials and improve the revenue cycle of the healthcare provider. Choosing a medical billing company in Hyderabad that provides appropriate guidance and training in the nuances of medical billing is vital if you want to make a career in this profession. Avontix is the best medical billing company in Hyderabad that provides the best training and scope for growth for a medical biller.
Visit: avontix
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