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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.


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