Common Rejections

Front-end rejections not only cause a delay in payment, but it adds additional time spent on a single claim. Most rejections can be avoided by making sure all of the required information is obtained and entered into the patient’s chart prior to generating the claim. Identifying some of the most common causes of rejections and knowing how to prevent them will guarantee payment in a more timely fashion.


    1. This is the most common mistake that causes claim rejections.
    2. Typos in the following fields cause a rejection almost every time:
      • ID numbers
        • For example, if a patient’s ID number has 2 digits transposed, the claim will reject stating the patient cannot be identified in the payer’s system.
      • Effective & Term Dates
        • Overlapping effective or termination dates can cause the incorrect insurance to be billed
      • Zip Codes
        • Having a typo in a zip code will cause a rejection
          • The typo can be in the patient, subscriber or insurance company zIp code
    • 3.While typos are a common and human occurrence, it is pertinent to check and verify your data prior to generating a claim.

Patient Information

        1. Missing patient demographics can cause a claim to reject. In order to submit a claim, you must have the following patient information:
          • Name
          • Date of Birth
          • Sex
          • Address
          • Insurance Information
            • Member ID Number
            • Effective Date
            • Group Number
            • Subscriber’s Information
          • Other Insurance Information (same as above)

Subscriber’s information

        1. If the patient is not the subscriber, the subscriber’s information is required to be on the claim. The information needed to avoid a rejection is:
          • Subscriber’s name
          • Relationship to patient
          • Subscriber’s date of birth
          • Subscriber’s address
          • Subscriber’s sex

Checking eligibility

      1. Inactive insurance plans cause the most claim rejections.
      2. Verifying eligibility prior to the office visit, especially at the beginning of a new year, will help prevent payment delays and claim denials
        • By checking the eligibility prior to the patient being seen, it can be verified that the the same insurance is still active or if the patient needs to provide the updated insurance information.

Invalid Medicare ID numbers

      1. Effective April 2019, Medicare began the switch from social security number based ID numbers and transitioned to using Medicare Beneficiary IDs (MBI) that are an 11 digit mixture of numbers and letters.
      2. Effective January 2020, the use of social security number based IDs resulted in rejections and/or denials as the use of the MBI was mandatory
        • Any Medicare Part B claims that are submitted with the social security number based ID will be rejected
        • MBIs can be found on the new Medicare ID cards or looked up on the Medicare provider website

Invalid Payer ID

      1. Insurance companies and clearinghouse software companies have adopted Payer ID Numbers. These numbers are 5 digits and indicate which payer the claim should be sent to. However, insurance companies update and change Payer ID Numbers frequently.
        • Blue Plans (BCBS, Blue Shield, Horizon Blue, Anthem, etc.)
          • Claims for blue plans are not sent to the home plan (the state the patient’s plan is located) but instead are sent to the local plan (the plan where the provider is located).
            • For example, a patient’s insurance card may indicate Blue Cross Blue Shield of Alabama; however, since the provider is located in South Carolina, the claim should be sent to BCBS  South Carolina

Most payer ID numbers can be found on the patients ID card. If you are concerned that it may be different from what is currently listed, please inform your biller or account representative to verify the correct information is listed prior to claims submission.

While there are more reasons that front-end claim rejections occur, the six listed above are easily avoided while making sure the demographic information is listed properly.


About PGM

Physicians Group Management (PGM) is one of the fastest-growing medical billing companies in the United States.  For over 35 years, PGM has been providing medical billing and practice management services and software to physicians, healthcare facilities, and laboratories.  PGM’s current client base encompasses the full spectrum of medical specialties, including Internal Medicine, Dermatology, Plastic & Reconstructive Surgery, Pathology, EMS & Ambulatory Services, Cardiology, Nephrology, Urology, Pain Management, OB/GYN, Gastroenterology, Independent Laboratory, and many more.  PGM’s medical billing and practice management solutions include:

– A full suite of practice management and medical billing solutions each tailored to the specific needs of your practice

– CCHIT-certified electronic medical record software and services

– Streamlined, customized credentialing services for providers of all sizes

– Practice management software that provides advanced financial and practice analysis tools, specifically designed to give enhanced visibility of operations at the click of a button

Laboratory billing software that offers best-in-class systems to streamline, and manage and track, financial and administrative processes