*// Heatmap Tool //*
ONC-ACB Certification ID: | Certification Date: Nov 11, 2019
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. ​

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:

How to Get the Most Out of Your Data

How to Get the Most Out of Your Data

Choosing a Practice Management System (PMS) with the right reporting tools for your needs is essential to running an efficient practice. Trying to sort through a mountain of data can be daunting if your information is not being presented in a clear and concise way.

Have you ever asked yourself any of the following questions?

• How well is my practice performing?
• Are there any areas that need improvement?
• Are we leaving money on the table?
• How do I make sure nothing is falling through the cracks?
• How do I get the most out of my data?

The Criterions PMS software provides a wide array of financial and clinical reporting tools to help practices get the most out of their data. Over the last 30 years, we have implemented many reporting features to address the needs of our clients, and we continue to evolve our software to match today’s fast paced world.

Users can select from any of our built-in reports including payment reports, productivity reports, daily/monthly reports, scheduling reports and patient reports which will be displayed on our built-in report viewer. Sample outputs for the Monthly report and the Unit Analysis report can be seen below:

Criterions Monthly Report Output
Criterions Unit Analysis Report Output

In addition to our built-in reports, Criterions PMS software is proud to offer flexible, customizable data exports for patient, claim, scheduling, and transaction information that allow users to create dynamic data outputs based on their changing needs. Users can select from a variety of filtering options and can choose exactly which fields to include in the output. For example, if you’d like to view your collected amounts for a designated date span, but want to filter based on a specific procedure code, diagnosis code, physician or insurance carrier, you can use the Claim Information export. Perhaps you’d like to see which of your patients had appointments for a particular appointment type in a certain location and you’d like to filter the results by age. You can utilize Criterions Scheduling Information export to generate this information.

With these powerful tools, the sky is the limit. Practices can create many of the reports they need on their own without requesting modifications to the existing, built-in reporting tools. The .csv output from these exports can be viewed in external programs such as Microsoft Excel, where advanced Excel users can perform further grouping and filtering to present data in a multitude of ways. Totals can be calculated based on any desired field, custom formulas can be applied, and various charting formats can be implemented to display the data graphically. With tools like this, you can ensure that you are getting the most out of your data by presenting it in a way that will help you meet your practice’s changing needs.

Interested in learning more about our PMS software? Contact us using the from below:

4 Reasons to Choose an Integrated EHR/PMS Solution

4 Reasons to Choose an Integrated EHR/PMS Solution

Adopting an Electronic Health Record (EHR) or Practice Management System (PMS) will provide many benefits to your practice. Often, practices use separate systems for their EHR and PMS needs; however, an integrated solution can enhance your team’s productivity. Why should your practice choose an integrated EHR/PMS solution? Here are 4 reasons:

1. Reduce Wasted Time

An integrated system reduces wasted time for providers and front office staff by allowing data to be shared between the EHR and PMS, which provides seamless coordination of business between departments. Users are able to input the data separately and access it individually, further reducing the risk of errors or duplicate entries.

2. Maximize Billing Revenue

Choosing an integrated solution helps you maximize billing revenue due to preset rules in the EHR/PMS that must be followed prior to submitting claims. An integrated system ensures accurate information is conveyed both ways, which is essential for claims processing. This reduces errors and ensures cleaner claims, which in turn generates higher revenues for the practice.

3. Master One System

Another important benefit to an integrated EHR/PMS solution is that your staff will only have one system to learn. Without an integrated solution, using multiple platforms for EHR and PMS leads to having to learn the nuances of two systems, and having to learn how to coordinate and share data between both systems. A fully integrated EHR/PMS system eliminates the need for the administrative resources that are necessary to manage multiple systems in a practice. This reduces the amount of time required to train staff on multiple systems and coordinate information flows between departments.

4. Save Money

Your practice will save money when bundling EHR and PMS systems. The cost of two systems, implementation, and training your team on multiple platforms can add up. By choosing an integrated system, your practice will save money immediately and in the long run.

An integrated EHR/PMS system provides a versatile and cost-effective solution to many practices.


To learn more about Criterions EHR/PMS solutions, contact us using the form below:

Request a Demo!