Insurance Claim Rejections vs. Denials

Insurance companies can either Reject or Deny claims, but the two are not synonymous. Understanding the difference is important as it will guide you to what needs to be done next for the claim. 

Claim Rejections:

A rejected claim contains one or more errors found before the claim was processed by the payer. Claims that get rejected are never entered into the payer's computer systems because the data requirements were not met. Errors will prevent the insurance company from paying the bill and the rejected claim is returned into EZDERM to be corrected.

Claims that have been rejected can be accessed from the Dashboard:

Or they can be accessed from the Billing menu option, by choosing Claims, and changing the status in the top right to Rejected: 

You can easily see the rejection message, which is sent directly from the payer or clearinghouse, by hovering your mouse over the red exclamation mark icon to the left of each respective claim:

This message will guide you to what information needs to be corrected before resubmitting the claim. This information can also be found from within the claim itself, in the Claim Log. 

A rejected claim can be resubmitted once the errors have been corrected.

Claim Denials:

Denied claims are claims that were received and processed by the payer and the payer chose to not pay on them. When an insurance company denies a claim, they have a record of that claim in their system.

These claims may violate the terms of the payer-patient contract, or they may just contain some sort of error that was only caught after processing. A denied claim cannot simply be resubmitted, the way that rejected claims can be. If the claim was denied, in general, you would need to send a corrected claim. If a claim was denied and you resubmit the claim (as if it were a new claim) then you will normally receive a duplicate claim rejection on your resubmission and the claim will remain unpaid.

Denials come back on either a paper Explanation of Benefits (EOB) to the office or via Electronic Remittance Advice (ERA) if your practice is enrolled to receive ERAs into EZDERM from the payer. Payers will include an explanation for why a claim is denied when they send the denied claim back to the office. Having that information available allows an appropriate appeal to be written or a reconsideration requested. 

Denied claims can also be quickly accessed from the Dashboard:

Or from the Claims section of the Billing menu, by filtering for claims in a status of Denied: