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Top 5 Claim Rejections (and How to Avoid Them!)

Top 5 Claim Rejections (and How to Avoid Them!)

At Criterions, we want to help your practice optimize the claim lifecycle. That is why we have partnered with TriZetto Provider Solutions to help your practice improve your clean claim percentage and reduce processing delays. By analyzing claims submitted by Criterions clients, we have identified the top 5 reasons claims are rejected and ways to avoid them:

1. This provider is not approved to send electronic claims to this payer. Enrollment is pending.

When a rejection like this is received through any clearing house, this means that the client is not yet enrolled, or is not set up within the EHR. This can be avoided with a simple check from the enrollment team.


2. The COB information does not balance.

This type of rejection is common, but avoidable. When a provider sees this rejection, it typically means that the claim was submitted twice to the same payer after a payment was already issued. When this happens, it throws the balance off, causing the claim to reject.

In order to prevent a rejection like this, clients can check the patients claim ledger and review what claims are being sent.


3. Patient/Subscriber is not eligible. Please verify member ID/Insurance/Coverage.

This rejection states that the patient has either new insurance or that the ID is invalid.

To prevent this from happening, you must make sure that the patient has an active insurance, and that the member ID is valid. In order to verify this information, the patient must be contacted to confirm if any updates have been made to their insurance.


4. Claim Rejected as a duplicate.

Coming across a rejection like this means that the claim was sent twice.

The easiest way to make sure this does not happen again is to ensure you are not sending claims that have been sent within 24hrs, or else the claim will reject as a duplicate.


5. The Payer ID Number is required and must be valid.

A rejection that stated the Payer ID is invalid means that the insurance carrier you are billing has a Payer ID which is not valid with the clearing house, as each clearing house has their own payer IDs.

To avoid this, make sure all Payer IDs are up to date within the EHR. To check if they are correct, you can contact the clearing house directly by phone or see if the clearing house has a link on their website that will help you identify the correct Payer ID.


By keeping an eye out for common claim rejection reasons, your practice will be able to avoid them and lower your claims rejection rate. This means that you will be able to reduce delay and increase coding compliancy.


For more information on TriZetto Provider Services, click here or complete the form below. ​

What is Health Information Exchange (HIE)?

What is Health Information Exchange (HIE)?

There is an increasing demand for interoperability amongst healthcare providers and patients for access to and sharing of a patient’s medical records electronically. Providers want to participate in the exchange of data to improve patient care and outcomes. Health information exchanges (HIEs) facilitate the exchange of patient medical information electronically – securely and efficiently. In 2019, the utilization of local, state, and regional health information exchanges by hospitals increased to over 50-percent [1].

Types of Health Information Exchange Data:

There are three types of HIE that each offer unique access to health information [2].

1. Consumer Mediated Exchange - In this type of exchange, patients have more control over their records and their use among healthcare providers.
2. Query Based Exchange - In this type of exchange, a healthcare provider can request and search patient medical information across multiple different healthcare providers.
3. Directed Exchange - In this type of exchange, coordinated care is facilitated by a bi-directional transfer of patient medical information between healthcare providers.

Why Practices Need Health Information Exchanges?

HIE helps healthcare providers provide high quality care to patients by improving the speed and cost of patient outcomes. According to Qsource [3], the transfer of health information helps practices to:

1. Avoid errors – interoperability is only successful when there is a reduction of errors, which leads to cost effectiveness. In addition, avoiding readmissions can also be cost effective.
2. Improve diagnoses – when healthcare providers have increased access to tests and information about a patient, patient care is more effective and efficient.
3. Reduce testing – unnecessary testing improves patient satisfaction, promotes quality of care, and reduces costs.

As the demand for HIE increases, medical providers should work with their EHR software provider to implement a solution that meets the needs of their patients.

For more information on how Criterions can support your practice with HIE, complete the form below:

[1] Jason, C. (2021, March 26). Stages of Health Information Exchange Implementation. EHRIntelligence. https://ehrintelligence.com/features/stages-of-health-information-exchange-implementation.
[2] CapMinds. (2020, November 16) “The Essential Guide To Health Information Exchange.” CapMinds Blog The Essential Guide To Health Information Exchange. CapMinds. www.capminds.com/blog/the-essential-guide-to-health-information-exchange/#.
[3] Qsource. (2019, November 6). QPP: What is Health Information Exchange and How to Make it Work for Your Practice. Qsource. https://www.qsource.org/qpp-what-is-health-information-exchange-and-how-to-make-it-work-for-your-practice/.

How Does FHIR Improve Patient Care?

How Does FHIR Improve Patient Care?

Fast Healthcare Interoperability Resources, or FHIR, is an interoperability rule that will enable on-demand information exchange of clinical records among providers and data systems. FHIR was created by the Health Level Seven International healthcare standards organization (HL7) specifically for healthcare organizations. The goal of FHIR is to assist practices in delivering more value to patients between appointments, so that they can focus on providing the best possible care to patients in the office. This will, in turn, result in more coordinated, cost-efficient care.

Too often, health systems are distracted by the technical or administrative processes that facilitate interoperability in healthcare. This causes providers to lose sight of their top goal: improving patient care by sharing the best information available at the point of care. By adopting the new healthcare data exchange standard, providers can more efficiently share patient data, payers can drive down costs and improve outcomes, and patients can take greater control of their health.

FHIR builds on previous data format standards like HL7, but it is easier to implement because it uses a modern web-based suite of API technology. FHIR makes it easy to provide healthcare information to healthcare providers and individuals on a wide variety of devices including computers, tablets, and cell phones. It also allows third-party application developers to provide medical applications which can be easily integrated into existing systems. FHIR helps Healthcare IT software providers rapidly create new innovative solutions to improve patient care. Because FHIR is a modern architecture solution and scales well, the next generation of applications can utilize FHIR to bring their solutions to market faster, and with greater impact.

Criterions partners with EMR Direct to help your practice improve patient care. EMR Direct can enable data from Criterions EHR at FHIR endpoints, for access to these resources by users you authorize, leveraging patient portal credentials already in place.

For more information on how to set up FHIR, complete the form below:

Case Study: DocCare

Case Study: DocCare


Since the launch of Criterions TCMS product in 1997, DocCare has been utilizing Criterions’ software solutions to increase efficiency in their office. At that time, the practice had three office locations, but have since expanded to seven offices across New York. DocCare has over 23 physician providers who support 18 medical specialties, and operates under the guidance of Dr. Joel Hershey, who has been the with DocCare for over 20 years. In his role as Medical Director, Dr. Hershey oversees the physician staff in their mission to provide high-quality care to patients. After many years of utilizing paper for all patient and office records, the practice made the switch to electronic documentation in 2011 when they implemented Criterions EHR software.

Although there were hesitations moving from paper to an EHR, Dr. Hershey can’t imagine going back to the burdensome process of paper documentation. Over the years, DocCare has added many new features and enhancements to their EHR. Because DocCare is setup on the cloud, any updates made to the software are automatically shared with the entire team. Dr. Hershey says, “There is new functionality and upgrades added often and it's making huge difference for our practice.” These updates help DocCare continually improve the experience for both patients and administrative staff.

In 2011, Dr. Hershey was one of the first doctors involved with the federal and New York State Meaningful Use programs that were implemented. This support helped DocCare achieve government reporting requirements and improve overall quality of care for patients. He shares,

“The Product Manager at Criterions worked closely with me to rebuild our EHR so that it produced all the correct information in the format that the government required, and we were one of the first groups in New York state who began meaningful use.”


Long-Term Success

Over the years, Criterions EHR has continued to grow with the needs of DocCare. The staff love that they are able to easily customize the EHR system setup for each individual employee. Alex Hernandez, IT Manager at DocCare says,

“The training we received from the Criterions team was very helpful. They showed us exactly what the system can do and from there we've been able to customize templates for all positions easily.”

He shares that because they hire new practitioners frequently, it is helpful that the system is intuitive and only takes about a day or two to get used to.

DocCare also appreciates the success they have had using their EHR to adapt to the challenges of 2020. Because of the outbreak COVID-19, practices had to quickly shift from seeing patients in person to meeting virtually. Looking back on this transition, Dr. Hershey recounts, “Last year when we started doing a lot of telemedicine appointments because of COVID-19, we were able to get the appointment types up and running in the same day.”

In addition to optimizing their software to handle telemedicine calls, DocCare was also able to easily contact patients who were at the highest risk of contracting COVID-19 to determine who should be contacted about getting the vaccine.

“We are able to quickly pull reports and send email blasts to specific people based on certain diagnosis groups or age groups,” says Dr. Hershey.

The reporting and emailing options within the Criterions software helped DocCare increase communication with patients, and in turn, increase patient satisfaction. Dr. Hershey explains, “We were able to pull a report in one minute to quickly improve the quality of what we can do.”

DocCare continues to provide comprehensive high quality medical care with the support of Criterions software. Together, we will continue to grow and offer new solutions that will improve the patient experience as well as increase efficiency for DocCare’s administrative staff.


Interested in learning how Criterions software can benefit your practice? Fill out the form below:

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