Claims are most often rejected due to incorrect or invalid information that doesn’t match what’s on file with the payer. Rejections can come from either the clearinghouse or the insurance payer. A rejection status does not necessarily indicate that the payer has determined that the claim is not payable.
Possible reason could be mismatched insurance information that you have entered in CMS-1500. Or it could be incorrect patient information i.e. incorrect patient demographics.
Insurance Coverage Expired
There are some cases in which patient is no longer covered under that insurance plan. If this is the case, you will either need to get new insurance information from your patient or bill the session to your patient i.e., patient responsibility. You should always verify patient benefits or patient eligibility before submitting any claim.
In such rejected claims double check payer ID on CMS-1500. You might be submitting claim to wrong payer (insurance company). You can call the phone number on the copy of the patient’s insurance card and ask them for their EDI Payer ID. Resubmit the claims with correct payer ID.
Wrong Insured ID Number
Recheck insurance ID number (1a) on CMS-1500 claim and patient’s insurance card. This is the unique ID that identifies the patient. Make sure that is entered correctly. Make sure you don’t have any invalid characters in the primary ID. Some of insurance companies will have trailing numbers at the end of their primary ID separated by a dash or a space. You may want to ask the payer if they want the trailing numbers in Box 1a of the CMS-1500.
Wrong Insured’s Information
Cross-check insurance information with an insurance card. It is always best to make sure you enter it correctly on CMS-1500. Sometimes you could have misspelled a name or entered the wrong birthdate.
How can you resolve Invalid MBR issue?
Resubmit the claim
You can edit the claim with correct details, from the error page, you can then click the resubmit claim electronically button from your practice management software to send the claim out with the new information.
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