Denied claims are claims that have been received and processed, but are determined to be unpayable. These claims may be denied for reasons such as, but not limited to, non-covered services, missing authorization, or duplicate billing. Denied claims appear with a reason code on the provider’s remittance advice.
- A Provider Claim Dispute (formerly known as Provider Claim Payment Appeal) is a post-service request for review of a denied claim typically following the adverse outcome of a Reconsideration Request, an Adjustment Request, or a denied or absent authorization.
Rejected claims are claims that contain one or more errors and are not accepted for processing, because the submission requirements have not been met. A claim that is returned to the provider for this reason must be resubmitted as a first-time claim on the original red and white claim form in order to be considered for processing and potential payment. Please be aware that claims must be submitted in a timely manner; the timely filing clock starts with the date of service on the claim, not the date that the claim is submitted for processing.