Rejected claims are claims in which errors were found and were returned for correction. These will generally appear under Rejections in the EDS section.
Some common reasons for claim rejection include:
· The claim was submitted more than once
· The patient information was incorrect
· The enrollee ID is missing or incorrect
· The CDT code submitted was revised or deleted
· The patient was incorrectly submitted as a dependent
· Invalid surfaces for anterior and posterior teeth
Denied claims are claims that were considered unpayable by the payer. These will generally appear under Rejections in the Payer section.
Some common reasons for claim denial include:
· Pre-authorization was required but not obtained
· Claim form errors (patient data, diagnosis, procedure codes)
· Claim was filed after insurer's deadline
· Insufficient medical necessity
· Use of out-of-network provider
There are two ways you can manage rejected or denied claims:
· From Your Practice Management Software - Mark the claim as read in EDS, open the claim in your practice management software and correct the errors there, and then resubmit the claim from your practice management software. This approach may be preferred because it ensures that your practice management software records are correct also.
Tip: Before marking the claim as read in EDS, you can right-click the claim, and choose Open in PMS from the shortcut menu to open that claim in your practice management software for editing.
· From EDS - Edit the claim in EDS, correct the errors, and then resubmit the claim. This approach may be quicker but could lead to confusion later if your EDS records don't match your Eaglesoft records.