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Reading a Claim Rejection

While it may be easy to see when a claim has been rejected, it is often more difficult to understand why a claim was rejected.  This article will show you how to read the claim history to gain a better understanding of how to fix a claim to be reimbursed.

Role Required: Practice Biller

The Claim History

1 - Created: This shows the time and date that the claim was originally created in TherapyNotes.

2 - Update from Clearinghouse: This is a message from our clearinghouse partner about the status of your claim.  Early status updates will include messages about your claim being accepted and processed by the clearinghouse.

3 - Status Changed: This message highlights a changed in your claim status.  When you see this in red, this is a visual indicator that the claim status changed to Rejected.  Above the Status Changed indicator will be one or messages providing additional information about why a claim was rejected.

Where Rejections Occur

Electronic claims can be rejected at several places along their journey.  TherapyNotes tries to reduce the frequency by alerting you to information that is missing from claims before you try to send them.  However, there are still several other entities that can reject your claim during its processing journey.  You can infer some basic information about the reason why your claim was rejected based on where the rejection happened.

Clearinghouse

When you see the message "File status: Accepted, Claim status: Electronic claim rejected by Clearinghouse" you can know that the claim was rejected at the clearinghouse level.  The clearinghouse performs a function called scrubbing on all electronic claims.  Scrubbing is the process of evaluating the information contained in the claim to ensure that it meets a variety of standards.  Some of these are national standards, such as ensuring that the service code submitted is a valid service code or HCPCS code or that the diagnosis included on the claim is represented by a valid ICD-10 code.  In addition, certain payers have contracted for additional validation, such as the format of the member ID.  Generally, if a claim is rejected at the clearinghouse level it is because some portion of the claim information did not meet standards.  Good starting places to consider are:

  • Service codes
  • Diagnosis codes
  • Taxonomy codes
  • Enrollments
  • Demographic information (addresses, phone numbers, birth dates)


Your Payers

If all the information on the claim meets the basic validation test requirements done during scrubbing, your claim will then be forwarded to the payer.  Payers generally process claims at two levels - EDI and adjudication.  EDI is the department that receives the claim information from the clearinghouse.  The EDI department performs an additional level of scrubbing, this time specific to the payer.  This is where the payer ensures all of the data on the claim matches what the payer has on file.  If a claim passes on to adjudication, this is when the claim is evaluated to see if it will be paid. Claims rejected at the EDI level may not show up on a provider representative's system if you call in for assistance with your claim.  Not to worry, your claim was still received by the payer.  Simply ask to talk with the EDI department instead for more information about your claim.

If your claim was rejected by the EDI department, there are several things to consider:

  • Client information must match what the payer has on file.  If your client got a new insurance ID number and failed to notify you, or moved and did not update their address with the payer, these can cause rejections.  Claims can also be rejected for spelling differences, the presence (or absence) of a middle initial, and many more seemingly trivial issues.
  • Your billing information must also match what the payer has on file.  Be sure that your payer has the correct license information, NPIs, business address, and taxonomy code(s) on file.
  • Be sure that you are approved to submit claims.  Even if you are out-of-network with a payer, they may require you to fill out some paperwork or even submit a W-9 before they process your claims.

If your claim was rejected during adjudication, your best course of action may be to contact the payer directly.  The service you provided may not be covered under the client's plan, or their coverage may not be active.


Understanding the Rejection Message

Whenever a claim status changes to Rejected, one or more messages usually also appear in the claim history with additional details about why the claim was rejected.  As seen in this image, rejection messages typically have a similar format:

  • Payer ID -  this allows you to be sure you know which payer is rejecting the claim.  This can be useful if the claim was submitted to the wrong payer, or the client's insurance information has been updated since the claim was initially submitted.
  • Status message - this typically does not tell you much more than that the claim was rejected.
  • Code - this code often refers to a standardized list of potential reasons as to why claims can be rejected, but can also reflect internal code lists of a payer.
  • Message -  this is the most useful component of the rejection message.  The message provides more specific information about the code, although the message can be fairly cryptic as well.  The message also often provides additional reference points, such as which data in the claim was invalid or what part of the claim contained incorrect information.  Search the TherapyNotes Help Center for your specific rejection message for more information about how to correct your claim.

Common Claim Rejections

The below list outlines some common rejection messages from the clearinghouse or payer, with suggestions for how to resolve before resubmission. If you need additional help figuring out what went wrong or how to fix it, please contact the TherapyNotes Support team with your Practice Code and the TherapyNotes claim ID at support@therapynotes.com.

 

For information on viewing Claim Status and Rejected Claims, read Electronic Claim History: Claim Status and Rejected Claims.

For a visual tutorial about resubmitting claims, read Resubmit Electronic Claims.

 

Code

Rejection Description

Suggested Resolution
B40435 The 'Subscriber Primary Identifier' cannot be the same as the 'Group or Policy Number' in 2000B/SBR-03 The subscriber’s Member ID for the policy cannot be the same as the Group Number. Check the policy information on the billing settings tab for the patient to correct.
H10030 'Subscriber Address' - segment contains no data. Empty segments must not be present. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H10030 Subscriber City, State, ZIP Code - segment contains no data. Empty segments must not be present. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H10614 Missing Mandatory 'Subscriber Address - Subscriber Address Line', required for HIPAA. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H20618  The value '#######' does not match the format for a "Person name", must be at least one letter. The referring provider on the Billing Settings tab must be formatted as a name, starting with a letter. Check the referring provider listed on the patient’s Billing Settings tab to confirm it contains a real name.
H24391 Missing HIPAA Required 'Subscriber City Name' in '2010BA'. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H24391 Missing HIPAA Required 'Identification Code Qualifier' in '2330B'. We are unable support the patient's secondary insurance with the current clearinghouse.  Remove the secondary policy from the claim before resubmitting.
H24391 Missing HIPAA Required 'Other Payer Primary Identifier' in '2330B'. We are unable support the patient's secondary insurance with the current clearinghouse.  Remove the secondary policy from the claim before resubmitting.
H25375 The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-to Address. The practice address cannot include a PO Box in Address Line 1 or Address Line 2. Update to using a physical street address in your practice information settings. If you wish payments to be sent to a PO Box, please use the practice Alternate Billing Address to enter this information.
H25376 The Entity's State at '2010BA' is required when the address is in the USA, including its territories, or Canada. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H25393  The Zip Code at '2010BA' is required when the address is in the US or Canada. The subscriber's address information must be completely filled out, including full address, state, and ZIP code. Complete the address fields for the subscriber of the policy on the patient's Billing Settings tab.
H51000 The Procedure Code '55555' is not a valid CPT or HCPCS Code for this Date of Service. Edit the note header for the associated date of service to select a valid service code before resubmitting.
H51080 The ICD-10 code submitted is not a valid diagnosis code. Edit the note for the associated date of service to ensure the primary diagnosis is coded with a valid ICD-10 code.
H51082 ICD-10 code 'A123' must be coded to the highest specificity. Edit the note for the associated date of service to ensure the primary diagnosis is coded to the highest possible level of specificity (often 1 or 2 decimal places).
W25211 The 'Other Insured First Name' is required when the entity is a person and the entity has a first name. Review the secondary policy on the patient’s Billing Settings tab and ensure all fields are completely filled out, including the subscriber's first name.
N/A PAYER SPECIFIC EDIT MEMBER ID MUST BE ALL NUMERIC, LENGTH 8 THROUGH 12 Review the Member ID for the policy on the patient’s Billing Settings tab to ensure it is accurate.  You can use a payer portal to verify eligibility before resubmitting.
N/A SUBSCRIBER ZIP INVALID FOR STATE Review the subscriber's address information on the patient's Info and/or Billing Settings tab to confirm the ZIP entered is accurate.
N/A DUE TO THE CHANGE HEALTHCARE CYBERATTACK AVAILITY DOES NOT CURRENTLY HAVE AN ELECTRONIC PATH AVAILABLE FOR THIS PAYER. PLEASE LOOK FOR ALTERNATE ROUTES FOR CLAIM SUBMISSION FOR THIS CLAIM UNTIL FURTHER NOTICE. Claims cannot be submitted for this payer until they find another inbound routing solution.  Please contact the payer for more details.
N/A SEGMENT REF (RENDERING PROVIDER SECONDARY IDENTIFICATION) IS USED. IT IS NOT EXPECTED TO BE USED WHEN NATIONAL PROVIDER ID IS MANDATED FOR USE AND NM109 IS USED IN LOOP 2310B. SEGMENT REF IS DEFINED IN THE GUIDELINE AT POSITION 2710. Contact support@therapynotes.com with your Practice Code and TherapyNotes Claim ID for further review.
N/A SEGMENT REF (BILLING PROVIDER UPIN/LICENSE INFORMATION) IS USED. IT IS NOT EXPECTED TO BE USED WHEN NATIONAL PROVIDER ID IS MANDATED FOR USE AND NM109 IS USED IN LOOP 2010AA. SEGMENT REF IS DEFINED IN THE GUIDELINE AT POSITION 0350. Contact support@therapynotes.com with your Practice Code and TherapyNotes Claim ID for further review.
N/A OTHER SUBSCRIBER ZIP OR STATE INVALID Review the subscriber's address information on the patient's Info and/or Billing Settings tab to confirm the ZIP and State entered are accurate.
H20751 Invalid ZIP Code ('79981106'). If no other specific information is provided, review all ZIP codes for the claim for accuracy (patient address, subscriber address, practice address, practice location, alternate billing address, and payer).  
H46001  The 'Billing Provider UPIN/License Information' was not expected because the NPI was sent as the primary identifier. Contact support@therapynotes.com with your Practice Code and TherapyNotes Claim ID for further review.
N/A SUBSCRIBER ID (LOOP 2010BA, NM109) MUST BEGIN WITH A THREE-CHARACTER PREFIX FOLLOWED BY UP TO 14 CHARACTERS WITH NO SPACES. FOR FEDERAL EMPLOYEE PROGRAM (FEP) SUBSCRIBERS, THE SUBSCRIBER ID MUST BEGIN WITH THE LETTER R FOLLOWED BY EIGHT NUMBERS WITH NO SPACES. Review the Member ID for the policy on the patient’s Billing Settings tab to ensure it is accurate.  You can use a payer portal to verify eligibility before resubmitting.
N/A INVALID CHARACTER IN SUBSCRIBER LAST NAME (2010BA NM103). PAYER ONLY ALLOWS CHARACTERS A-Z, A-Z, AND SPACE. NO SPECIAL CHARACTERS ALLOWED. Review the subscriber’s information and remove any punctuation within the last name.  This payer does not accept periods, hyphens, or other non-space characters in names.
H10657  Loop 2400 exceeded max use count. This payer cannot accept more than 10 line items per claim.  Resubmit the claim, breaking it up such that no more than 10 line items (service codes) appear on each claim.
N/A THE SUBSCRIBER ID (2010BA NM109) IS NOT VALID WITH THE CLAIM FILING INDICATOR (2000B SBR09) FOR THIS PAYER. Review the Member ID for the policy on the patient’s Billing Settings tab to ensure it is accurate.  You can use a payer portal to verify eligibility before resubmitting.  If correct, ensure the insurance type on the Payer Info tab is accurate for this payer.
N/A THE CLAIM FILING INDICATOR/PAYER NAME COMBINATION IS INVALID FOR THIS PAYER. Confirm the insurance type on the Payer Info tab is accurate for this payer.
H25371 Telephone/FAX number in PER must be exactly 10 positions long. The value '71479451787149103648' is too long. Review your practice phone number, as it has too many characters.
N/A SUBSCRIBER ID (LOOP 2010BA, NM109) MUST CONTAIN TWELVE OR LESS ALPHANUMERIC CHARACTERS. Review the Member ID for the policy on the patient’s Billing Settings tab to ensure it is accurate.  You can use a payer portal to verify eligibility before resubmitting.
N/A Invalid Character in Data Element Data in error Review the payer name and/or practice name for invalid characters.  Often, punctuation is not allowed in these fields.
N/A THE BILLING PROVIDER NPI (LOOP 2010AA, NM109) AND THE SERVICE FACILITY NPI (LOOP 2310C, NM109) CANNOT BE THE SAME. Contact support@therapynotes.com with your Practice Code and TherapyNotes Claim ID for further review.