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Fixing Claims

Claims fail in two very different ways, and the fix differs accordingly. Everything that needs your attention is surfaced in the Needs Attention card on the Insurance hub.

Rejections (stopped before processing)​

A rejection means the claim never made it into the payer's adjudication system — the clearinghouse or the payer's front door bounced it, usually for a data problem: an identifier mismatch, a malformed member ID, a missing element. Rejected claims are not on file with the payer.

  1. Open the claim — the rejection reason is triaged into a category (Insurance Information, Patient Demographics, Diagnosis & Billing Codes, Provider / Billing Info, Coverage & Benefits, or Timely Filing), each with step-by-step guidance and a shortcut to the section that needs fixing.
  2. Click Fix & Resubmit — correct the flagged fields (member ID, diagnoses, service lines, Place of Service) right in the resubmission form.
  3. Submit — because the payer never processed the original, the resubmission goes out as a fresh claim, not a duplicate, and the old one is closed out automatically.

Denials (processed and refused)​

A denial means the payer adjudicated the claim and decided not to pay — no coverage on the date of service, no authorization, non-covered service, timely-filing, etc. Denials come with reason codes on the ERA/EOB.

  • If the denial is due to incorrect information, click Edit & Resubmit Corrected — the correction goes out as a replacement claim (frequency code 7) carrying the original payer claim number in Box 22, so the payer processes it as a correction rather than a duplicate; the original is closed out automatically
  • If you disagree with the decision, that's an appeal — filed with the payer per their appeal process, with supporting documentation
  • If the denial says deductible, that's not a true denial — the balance moves to the client (Balances & Deductibles)

Claim Sent to the Wrong Payer​

Void it with the wrong payer if it was accepted (below), fix the client's coverage so the right payer is attached, and file a fresh claim to the correct payer.

Voiding a Claim​

To retract a claim that shouldn't have been filed at all (wrong client, duplicate, service never happened), open the claim and use Open to Void — the void goes to the payer as a frequency-code-8 claim. Voiding tells the payer to cancel the claim; the appointment returns to your control so you can rebill it correctly or leave it self-pay.

When It's the Enrollment, Not the Claim​

If every claim to one payer bounces, the problem is usually upstream — check the payer's enrollment status before debugging individual claims.