Gastroenterology Coding Alert

Question: One of the claims I submitted was recently rejected, and I can’t find anything wrong with the codes I submitted. How do I appeal the claim?

Idaho Subscriber

Answer: You can’t appeal the rejection because the claim was never technically filed. You can only appeal once the payer denies the claim. The errors on your claim may not have anything to do with the codes. It might be an incorrect ID number, or something similar.

Here’s the difference between rejection and denial:

Rejected claim: A claim gets rejected by the payer if there are errors caused by incomplete information or inaccuracies. These claims have not yet been reviewed by the payer. They are returned to the provider who then corrects the errors and resubmits the claim. Providers must fix the errors or supply the missing information in the rejected claim and resubmit it to the payer for processing. Once resubmitted, the claim can be either paid, denied, or rejected again based on the updated information.

Denied claim: A claim gets denied once the payer process it and deems it unsatisfactory based on its policies or coverage. In other words, denied claims have been reviewed and determined to be non-payable for various reasons such as lack of medical necessity, incorrect or missing information, expired timely filing limits, or services not covered by the patient’s insurance plan. You can appeal these claims by providing additional documentation or information to the payer and resubmitting the claim.