Practices using the electronic claims feature (eClaims) can transmit claims electronically to insurance companies. When electronic claims are rejected, it is because certain information is missing that is preventing the claims from being fulfilled.
A claim can be rejected from the insurance company or it might be rejected within eServices before it can even get to the insurance company.
To determine where the claim was rejected from, you can look at the top of the rejected claim when you are viewing the eService Report (Location > Archives > eServices Reports) within Sensei Cloud:
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Claim Status Report For XX/XX/XXXX | Account: ########
If the top of the claim is in this format, the claim was rejected by the insurance company. -
Transmission Log For XX/XX/XX Account: ########
If the top of the claim is in this format, the claim was rejected before it reached the insurance company.
Claim Rejection Reasons and Resolutions
The following table describes some of the common insurance claim rejection reasons and how you can resolve them.
Note: Please note that after any of the following actions have been taken to resolve the claim rejection, the affected claim(s) will need to be cancelled and resubmitted. In some cases, the charges will also need to be recreated. See How to Cancel and Resubmit a Claim for more information.
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Entity not approved as an electronic submitter | The billing NPI needs to be registered for electronic. Reach out to a customer service representative for assistance. |
Missing or Invalid rendering NPI: |
This means that there is a location where the National Provider Identifier (NPI) is not properly entered. Check the following:
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Missing Patient Sex |
Ensure that the patient's gender is selected within their patient record. See How to Add a Patient Record for more information. |
For more detailed information, see remittance advice |
This rejection type is common for Delta Dental. Try any of the following options:
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Entity Date of Birth missing or invalid. -Patient |
First, confirm with the patient that their date of birth is entered correctly in their patient record within Sensei Cloud. If the date of birth is incorrect, update the date in their record. If the date of birth is correct in Sensei Cloud, proceed with one of the following options:
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Invalid provider license number |
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Invalid address: State must be two characters. |
This is often caused by the policyholder or patient not having an address entered or having an address entered that is missing the state. Confirm the policyholder and patient's address are entered correctly and include the necessary information (including the state). |
Invalid Statement Type: 00 |
Ensure that the customer has an accepted card type within the Automated Statements tab. From the Administration tab, select eServices > Automated Statements. See How to Set Bulk Automated Statement Preferences for more information. |
Procedure Code Description Note is Required |
Locate the insurance claim from either the Patient tab (Patient > Insurance > Claims Management) or Location tab (Location > Claims > Claims Management). Click on the claim, and then click Edit Addl Info. Ensure that Box 35. Remarks has the relevant information entered. If Box 35 is not filled out:
See Insurance Claim Rejected With Procedure Code Description Note is Required and How to Create and Manage Claims for more information. |
Services line information error. Tooth number or letter missing or invalid. (Often followed by which procedure code is affected) |
Ensure that the claim has the correct tooth number entered for the procedure code mentioned in the rejection. |
Payer name cannot be blank | Ensure that the payer name has been filled out correctly. See How to Add or Edit an Insurance Payer for more information. |
ACK/Returned - Policy Cancelled. - Insured or Subscriber | This is a response from the insurance company stating that the policy has been cancelled. |
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