Do your medical claims get rejected often? Are you losing money from denied claims? Studies show 15-20% of all medical claims get rejected. Wrong patient info causes 42% of claim rejections. Coding errors account for 35% of all denials. Missing or incomplete data causes 27% of rejections. Practices lose $5 million per year from rejected claims on average.
Medical claim rejections happen when insurers refuse to pay. Rejected claims need to be fixed and sent again. This wastes time and delays payment to practices. Research shows 65% of rejected claims never get resubmitted. Staff spend 20 hours per week fixing rejected claims. Quick fixes can reduce rejection rates by 60%. Understanding rejection reasons helps practices get paid faster.
This guide covers the most common claim rejection reasons. We show simple ways to fix each problem. Learn how to prevent rejections before they happen. Improve your claim acceptance rates starting today. These tips work for practices of all sizes. Get paid faster by avoiding common billing mistakes.
Patient Information Errors
Wrong patient info is the top reason claims get rejected. Small mistakes in names or numbers cause big problems.
Incorrect Patient Demographics
Name spelling must match the insurance card exactly. One letter wrong causes automatic claim rejection. Date of birth must be correct format. Address errors prevent claim processing, too. Gender code must match insurance records. Social security numbers need careful verification.
Insurance Information Mistakes
Policy numbers must be entered correctly always. Group numbers need an exact match with the card. Insurance ID numbers cause rejections when wrong. Subscriber info must match the policyholder. The relationship to the insured must be right. Primary vs secondary insurance order matters.
Eligibility Verification Failures
Check patient eligibility before every visit. Insurance coverage may have changed since the last visit. The patient may have switched to a new plan. Coverage may have expired without the patient knowing. Benefits may not cover the service provided. Real-time verification prevents eligibility rejections completely.
Coding Errors and Mistakes
Wrong codes account for 35% of all claim rejections. Using outdated or incorrect codes causes denials.
ICD-10 Diagnosis Code Errors
Diagnosis codes must be valid and current. Outdated codes get rejected automatically by systems. Codes must be specific enough for service. Too general codes cause medical necessity denials. Code must match the treatment provided exactly. Maximum specificity required for claim acceptance.
CPT Procedure Code Mistakes
Procedure codes must match the service performed exactly. Bundled codes cannot be billed separately. Modifier usage affects code acceptance rates. Time-based codes need proper documentation support. Add-on codes require the primary code first. Unlisted codes need special documentation attached.
Medical Necessity Issues
| Common Issue | Rejection Rate | Fix Time | Prevention Method |
| Wrong diagnosis | 25% | 2-3 days | Better coder training |
| Missing info | 30% | 1-2 days | Complete documentation |
| Non-covered service | 20% | 5-7 days | Prior authorization |
| Incorrect code combo | 15% | 2-4 days | Edit check software |
Missing or Incomplete Information
Incomplete claims get rejected automatically by insurers. Every required field must be filled out.
Required Fields Left Blank
Claim forms have many required data fields. Leaving any field blank causes rejection. Date of service must be included. The place of service code is required. Rendering provider info must be complete. Diagnosis codes cannot be missing ever. Check all fields before claim submission.
Missing Documentation
Some claims need attachments to process correctly. Medical records required for complex cases. Operative reports needed for surgical claims. Prior authorization numbers must be included. Referral info required for specialist visits. Missing attachments always cause automatic rejection.
Incomplete Treatment Information
Service description must be clear and complete. Duration of service must be documented. Units of service must be specified. Modifiers need proper justification in notes. Start and stop times are required for some. Treatment location must be documented clearly. Complete info speeds claim processing time.
Authorization and Referral Problems
Many services need prior approval from insurers. Missing authorization causes automatic claim rejection.
Prior Authorization Not Obtained
High-cost services always need prior authorization. Elective procedures require approval before service. Specialty referrals may need authorization, too. Auth must be obtained before the service date. Auth numbers must be included on the claim. Expired authorizations cause claim rejections automatically.
Referral Requirements Not Met
HMO plans require referrals for specialists. Referral must be active on the date of service. Referring provider info must be included. Referral numbers needed on specialist claims. Self-referrals get rejected by HMO plans. Update referral info in the system for patients. Missing referrals cause immediate claim rejection.
Out-of-Network Issues
Patient saw an out-of-network provider without approval. The plan may not cover out-of-network services. Higher patient responsibility for out-of-network care. Emergency services may have different rules. Pre-certification is needed for out-of-network elective care.
Duplicate Claims and Timely Filing
Submitting the same claim twice causes rejections. Insurance systems flag duplicate submissions automatically.
Duplicate Claim Submissions
Resubmitting the claim before the first one is processed. System errors can create duplicate entries. Staff may not know the claim already submitted. Insurance systems reject obvious duplicates automatically. Check claim status before resubmitting anything. Use claim tracking software to prevent duplicates.
Timely Filing Deadline Missed
Most insurers require claims within 90 days. Some plans have shorter filing deadlines. Claims submitted late get rejected automatically. Timely filing limits vary by payer type. Medicare has a one-year filing deadline. Track submission deadlines for all payers. Late filing rejections cannot be appealed.
Coordination of Benefits Errors
| COB Issue | Rejection Cause | Fix Strategy |
| Wrong primary | Other insurance should pay first | Verify COB with the patient |
| Missing COB info | Secondary needs primary EOB | Include all required docs |
| Incorrect amounts | Math errors in billing | Double-check calculations |
| Timing errors | Filed to the wrong payer first | Follow proper filing order |
Technical and Submission Errors
Electronic claim submission can have technical problems. Format errors cause automatic claim rejection.
Electronic Claim Format Errors
The claim file must meet the payer format requirements. Missing segments cause format rejection errors. Invalid characters in data fields used. File size limits exceeded for submission. Batch claims may have individual errors. Test claims before mass submission occurs. Format errors reject the entire claim batch.
Clearinghouse Rejection Issues
Claims rejected at the clearinghouse before reaching the payer. Clearinghouse edits catch errors early in the process. Failed edits must be corrected quickly. Claims stuck at the clearinghouse never reach the insurer. Clearinghouse reports show rejection reasons clearly.
System and Software Problems
Billing software may have bugs or errors. Updates can cause unexpected claim problems. System crashes during claim submission occur. Internet connectivity issues prevent transmission. Software compatibility problems with payer systems. Backup procedures are needed for system failures.
Prevention Strategies
Preventing rejections is better than fixing them later. Good systems and training reduce rejection rates.
Staff Training and Education
Train the billing staff on common rejection reasons. Review rejected claims together as team. Provide coding updates when rules change. Test staff knowledge with practice scenarios. Offer continuing education opportunities for growth. Document all training sessions for records. Well-trained staff make fewer claim errors.
Claim Scrubbing Software
Use software to check claims before submission. Automated edits catch common errors early. Real-time eligibility checks prevent coverage issues. Code validation ensures codes are valid. Missing field alerts prevent incomplete claims. Software investment pays off through fewer rejections.
Regular Audits and Reviews
Review sample claims monthly for errors. Check denied claims for patterns noticed. Monitor rejection rates by staff member. Track common errors and provide training. Implement fixes for repeated mistakes found. Monthly audits prevent small problems from growing.
Conclusion
Common reasons medical claims get rejected include patient info errors. Coding mistakes and missing data cause many rejections. Auth and referral problems lead to claim denials. Duplicate claims and late filing cause automatic rejections. Technical errors prevent successful claim submission. Staff training and claim scrubbing prevent most rejections. Regular audits catch problems before they grow.
FAQs
What is the most common claim rejection reason?
Wrong patient info causes 42% of rejections. Name spelling and policy numbers cause most errors. Insurance info must match cards exactly. Verify patient details at every visit.
How quickly must claims be submitted?
Most insurers require claims within 90 days. Medicare allows one year from the service date. Check each payer’s specific filing deadlines. Track deadlines to avoid late rejections.
Can rejected claims be resubmitted?
Yes, fix errors and resubmit corrected claims. Most rejections can be fixed and paid. Submit corrections within the timely filing limits. Track resubmissions to ensure payment received.
What is the difference between rejection and denial?
Rejections never reach the insurance company system. Denials are processed, but paymentis refused. Rejections need fixing and resubmission always. Denials may need appeals to overturn.
How can I reduce claim rejection rates?
Verify patient info at every visit, always. Use claim scrubbing software before submission. Train staff on common rejection reasons. Conduct monthly audits of submitted claims.
