After filing a medical claim, your claim may get either “rejected” or “denied.” While these sound like the same thing, they are different. In this video, the presenter explains the difference between the two.
As explained by the presenter, a rejection happens before adjudication. There are a couple of different types of rejections, including a clearing house rejection from your clearing house, and a payer rejection, which will have something to do with an error in your claim.
These are both detailed in the video.
A denial, on the other hand, happens at adjudication. That means that there is nothing technically wrong with the claim to keep it from getting through either your clearinghouse or the payer. However, a denial will happen as a determination that your benefits or a policy of the provider do not match what is being requested in the claim.
Knowing the differences with medical billing is extremely valuable because it will help you know if you should continue to pursue a failed claim or not. If it turns out that it was rejected, there is likely something small that needs to be fixed and then you can resubmit the claim with the hopes that it will be accepted.
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