“Denied” vs. “Rejected” Claims

Fall 2020

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.