The medical claim lifecycle can be complicated and confusing. DocStation's Revenue Cycle Management team has the expertise to simplify and streamline this process so you can focus your time on patient care. In this brief article, we'll share this knowledge so you too can quickly troubleshoot and resolve claims that are in Invalid, Rejected, or Denied statuses.
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Invalid Claims
A claim will transition to the Invalid status if the patient eligibility check does not verify active coverage or if the claim does not pass a clearinghouse validation. The details about why the claim is invalid will show in the History section of the claim.
In this example, the claim failed the eligibility check because the subscriber ID isn't correct for the patient. This could be because the patient does have active coverage but under a different subscriber ID, or it could be that the patient doesn't have active coverage with that payer. To fix this, verify the patient's medical coverage, then update the ID and/or payer, then submit again.
Editing an Invalid Claim
All fields on invalid claims can be edited until the claim is ready to submit again. The claim will have passed this status when it moves to Processing status.
Navigate to the claim
Click the arrow to expand the History event that shows the reason the claim failed
Click the field that needs to be updated
Make the correct selection, e.g. edit the subscriber ID; choose a different payer from the dropdown menu, etc.
Click the attestation check mark and Submit button at the bottom of the claim again
Rejected Claims
A claim will transition to Rejected status if it does not meet the acceptable criteria for the clearinghouse and/or payer. A rejected claim has not technically been adjudicated and is not recorded for a payer the same way a Paid or Denied claim is.
In this example, the payer has rejected the claim because the payer was unable to identify active coverage for the patient. Verify the patient's medical coverage, then resubmit the claim with the corrected subscriber ID and/or payer.
Editing a Rejected Claim
A rejected claim can be transitioned to an editable status (Draft), if applicable, and then resubmitted.
Navigate to the claim
Click the arrow to expand the History event that shows the claim marked as Rejected to see the reason why
Click the Resubmit button to move the claim back to Draft status
Click the field that needs to be updated
Make the correct selection, e.g. edit the subscriber ID; choose a different payer from the dropdown menu, etc.
Click the attestation check mark and Submit button at the bottom of the claim again
Denied Claims
A claim will transition to Denied status after it has been adjudicated by the payer and the payer has determined the claim should be denied coverage and/or payment. A payer typically provides information to support the denial outcome by way of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs). Hover over the CARC/RARC to see the description of the code. To learn more about these claim codes, check out this article.
In this example, the claim was denied because the provider is not in network with the payer.
Editing a Denied Claim
When applicable, a denied claim can be transitioned to an editable state (Draft) and resubmitted for re-adjudication.
Navigate to the claim
Click the arrow to expand the History event that shows the claim marked as Denied
Click the Resubmit button to move the claim back to Draft status
Click the field that needs to be updated
Make the correct selection, e.g. edit the subscriber ID; choose a different payer from the dropdown menu, etc.
Click the attestation check mark and Submit button at the bottom of the claim again
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