Rejection or denial, two different issues but both mean “no payment” for insurance claims.

So many of the dental offices I speak to have problems with claims because there is confusion over a denial versus a rejection.

Many times claims are rejected when they reach the clearinghouse because the information does not reflect what the insurance company has on file for the patient.  For instance something as simple as gender can trigger a rejection.  Most dental software have a default of male gender and it must be changed to reflect the female gender of the patient.  Many errors that cause rejections come from the operator or front office person entering the patient information in the patient’s screen which is what populates the insurance claim.   This is not just eclaims but paper claims which take a lot longer to hear about because of the slow mailing process.  You may not hear about a paper mailed claim rejection for weeks.

Denied claims have been processed by the payer and deemed ineligible for payment due to one or several reasons such as but not limited to missing information such as radiographs, periodontal charting, narratives and diagnostic codes or incorrect CDT codes,  or it could be denied due to policy limitations in the contract with the insurance company or frequency limitations on the plan.  There are a lot of reasons and it takes time and training to be able to spot the somewhat vague denial verbiage that the insurance company sends back on the EOB.   Learning how to file “clean claims” is necessary to ensure cash flow.