Below you will find out the most common reasons for why a claim has been rejected, and what you need to do to fix them.
Common Rejection Reasons
Issue with the Subscriber and/or Patient Information
DI Insurance statuses to look out for:
Patient/Subscriber Information
Issue Subscriber and Subscriber ID not found
Missing/Invalid Subscriber ID
Subscriber and policy number/contract not found
Invalid Subscriber
Cert not valid
This claim could not be processed since the submitted combination
Employee Number Not Found on Carrier Records
INSURED ID NOT FOUND ON PAYOR FILE
Subscriber and policyholder name not found
Patient eligibility not found with entity
INSURED ID NUMBER INVALID
These statuses indicate that the subscriber and/or Patient doesn’t have active coverage with the insurance carrier the claim was submitted to or that the submitted information doesn’t match the insurance carrier’s records.
How to correct
The patient/subscriber information must match the insurance carrier's electronic file exactly. Before resubmitting make sure that the following information is correct.
Verify the claim was submitted to the correct insurance carrier (i.e., Federal vs. Commercial)
Check the patient and subscriber's names for abbreviations, middle initials, nicknames or typo’s
Verify the subscriber/patient haven’t moved or made changes to their name
Verify the insurance information matches that on the submitted claim. This information can be verified by viewing the Patient’s Insurance card, website or by phone.
Name
Address
Date of Birth
Subscriber ID #
Group #
Relationship to the Subscriber
Gender
Once you’ve found the issue, correct the information and resubmit the claim either in your Practice Management Software or clicking Send Claim within the DI Insurance feature.
ADA Code Validation Error
DI Insurance statuses to look out for:
Claim Failed ADA Code Validation
Line Information
Missing/Invalid tooth number or letter
These statuses indicate that procedure line information is incorrect. There could be due to an outdated procedure code or a requirement that was not fulfilled for a tooth number or area of the oral cavity.
How to correct
Verify that the procedure codes are active CDT codes
Verify if the procedure code requires an area of the oral cavity or tooth number and that the procedure code submitted includes the appropriate area of oral cavity or tooth number (i.e., Maxillary procedure code uses Maxillary area of oral cavity)
Verify if the procedure code does not require an area of oral cavity or tooth number that it is not included on the claim
Once you have identified the issue you can correct and resend from your Practice Management Software; or you can click on the Procedure Tab within the claim to edit and then click Send Claim.
Invalid or Missing Patient Address
If you see this status, it indicates that the claim is missing the patient and/or subscribers address information.
How to correct
Check for missing patient/subscriber home address information
Verify that the patient/subscriber zip code is complete and valid in either the format of 5 digits or 5+4 digits
View the Patient tab on the claim and add any missing address information and click Send Claim.
Entity’s Address is Missing
This status indicates that there is an address missing on the claim
Verify the addresses are complete for the following entity’s:
Insurance Carrier
Patient/Subscriber
Treating/Billing Provider
Check for P.O. Box in the Treating Address field
Insurance Carrier
Patient/Subscriber
Treating/Billing Provider
How to correct
Look over the Patient and Provider tabs on the Claim for missing or incomplete address information. Once the issue is found and updated click Resend Claim.
Incorrect or missing insurance carrier information
DI Insurance statuses to look out for:
Missing/Invalid Insurance Address
Regence claims must include the Carrier ID in the Carrier Name field
How to correct
Verify that the carrier plan name is exact and matches the carrier address on the claim
Verify the carrier address is complete and correct by checking the insurance card, website or by phone.
Update the insurance company's name and address and resend the claim from your Practice Management Software.
Treating/Billing Information is Incomplete or Missing
DI Insurance statuses to look out for:
Missing/Invalid NPI number
INVALID SEGMENT - NM1R (treating provider information missing)
NPI Missing or Invalid
These statuses indicate that the treating or billing provider's information is not complete.
How to correct
Verify that there is both a treating and billing provider NPI number submitted on the claim that is 10 digits and begins with a 1
Verify that all other billing/treating provider information is correct and complete
View the Provider tab for the claim and add or edit any missing or inaccurate information and click Send Claim.
The How to correct sections may direct you on how to correct an error in DI Insurance, however we recommend also updating the information in your Practice Management Software to ensure rejections do not recur.
DI Insurance is available with your Dental Intelligence product bundle. Dental Intelligence has partnered with Vyne to provide this service to our customers. If you haven't added the DI Insurance module that includes claims verification and claims submission Click Here! A representative of our team will be reaching out to you to help you get this module set up.