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Kareo Help Center

Best Practice to Avoid Rejection - Submitting to a Payer for the First Time

Intro

Claim denials and rejections are two of the biggest obstacles in getting electronic claims processed and accepted by the payer. Unfortunately they are a fact of life in medical billing and impossible to avoid. However, there are steps that can be taken to reduce the number of denials and rejections received by your practice to a minimum and ensure your electronic claims are paid:

Practice Setup

Ensuring your practice is properly set up in Kareo is essential for avoiding claim denials and rejections. In order to verify you are setting up your account correctly, first gather all the necessary information to ensure you are billing appropriately to each insurance:

 

Practice Information

The practice information entered into Kareo should match the practice's credentials. Payers may reject any claims with submitted information that does not match what they have on file.

Practice Name

For electronic claim submission the name entered in this field cannot exceed 35 characters. Doing so, will result in a claim rejection. This information will populate to Box 33 of the CMS-1500 form.

Follow the instructions below to verify the required information for the practice:

  1. Click Settings > Practice Information.
  2. The practice name in the Name field should be 35 characters or less including spaces.
  3. If necessary, enter the Group NPI field with the credentialed group NPI.
  4. Verify the tax ID in the EIN field is linked to the practice.
  5. The practice's address in the "Address" field under the Contact Information section should be a physical address with a 9-digit zip-code.
  6. Enter the address into the USPS Zip Code Look Up tool to validate the 9-digit zip-code.
  7. If the 9-digit zip-code is not correct, enter the correct information into the "Address" field.
  8. Click Save.

Group NPI and Tax ID

The credentialed group NPI and Tax ID (EIN) should be entered into the practice information. This will populate Box 33A and 25 of the CMS-1500 form.

Practice Address

The practice address must be a physical address and not a P.O. Box. A 9-digit zip code is also required.

Zip code rejections are among the most common and easiest to avoid. Most payers (including Medicare) will reject claims with an invalid or 5-digit zip. If you do not have the full 9-digit zip code, we recommend searching the USPS website.

Provider Setup

The provider's information entered into Kareo should match the provider's credentials. Payers may reject any claims with submitted information that does not match what they have on file.

General Tab

The individual NPI should match the NPPES NPI Registry. This will populate Box 24J and 33A (if billing individually) of the CMS-1500 form.

The provider address must be a physical address and not a P.O. Box. A 9-digit zip code is also required.

Zip code rejections are among the most common and easiest to avoid. Most payers (including Medicare) will reject claims with an invalid or 5-digit zip. If you do not have the full 9-digit zip code, we recommend searching the USPS website.

 

Claim Settings Tab

The default billing information (NPI and Tax ID/SSN) is based how the provider is credentialed with most payers. This will populate Box 24J and 33A of the CMS-1500 form.

If the billing information varies for a specific payer or service location, the Override Claim Settings will need to created or validated.

Follow the instructions below to verify the required information for the provider:

  1. Click Settings > Providers.
  2. Look for and open the provider record that needs editing.
  3. Validate the NPI in the Individual NPI field
  4. The Address field should have a valid address with a 9-digit zip-
  5. Enter the address into the USPS Zip Code Look Up tool to validate the 9-digit zip-code.
  6. If the 9-digit zip-code is not correct, enter the correct information into the Address field.
  7. Click on the Claim Settings Tab.
  8. The NPI dropdown should display the billing information that will be billed to most payers.
    • Selecting "Bill with Group and Individual NPI" will bill claims under the practice's Group NPI.
    • Selecting "Bill with Individual NPI Only" will bill claims under the provider's Individual NPI.
      • Check the "Override Group NPI?" check box to enter a different Group NPI than the one in the practice setting for this provider. Note: This will apply to all payers.
  9. Click Save.

 

 

Payer Information

Gathering the correct payer information before billing will ensure that the claims will not reject for invalid setup information.

 

Payer ID

Ensure you have the correct payer ID for all insurances your practice/provider will be billing in the insurance company record. Also ensure that the correct insurance company is attached to the patient's insurance policy.

Submitting claims to the wrong payer ID can lead to the claims either being rejected or processed by the wrong payer.

Follow the instructions below to enter the verified payer ID:

  1. Click Settings > Insurance > Find Insurance Company.
  2. Look for and open the payer that needs correcting. Or create a New Insurance Company.
  3. Click on the Electronic Claim tab.
  4. Verify that the payer name/payer ID matches the information on the patient's insurance card.
  5.  Click Save.

Note: Any changes made on the Edit Insurance Company settings will apply to ALL insurance policies and plans within the practice tied to this insurance company.

Make sure to only select a UB Payer ID for Institutional (UB-04) claims submission. Do not select a UB Payer ID for Professional (CMS-1500) claims.

Payer Address

Ensure you have the correct billing address for all insurances your practice/provider will be billing in the insurance plan record.

Zip code rejections are among the most common and easiest to avoid. Most payers (including Medicare) will reject claims with an invalid or 5-digit zip. If you do not have the full 9-digit zip code, we recommend searching the USPS website.

Follow the instructions below to enter the verified payer’s address:

  1. Click Settings > Insurance > Find Insurance Plan.
  2. Look for and open the payer that needs correcting. Or create a New Insurance Plan.
  3. Enter the payer's address from the patient's insurance card in the Address field.
  4. Enter the address into the USPS Zip Code Look Up tool to validate the 9-digit zip-code.
  5. If the 9-digit zip-code is not correct, enter the correct information into the Address field.
  6. Click Save.
  7. Follow steps 2-6 for each existing insurance plan.

Payer Credentialing Information

Ensure you have the correct billing/contract information (Billing NPI and Tax ID/SSN) that each provider bills under for each payer.

Tip: Unsure where to find the correct payer/credentialing information?

  • Contact the payer's Provider Services department
  • Have a copy of a paper claim paid on by the payer?
    • Payer Address: Top right of CMS-1500 form
    • BIlling NPI: Box 33a
    • EIN/SSN: Box 25

We recommend tracking the credentialing information in Kareo in either of the following areas:

  1. Provider Record
    1. Click on Settings > Providers.
    2. Look for and open the provider that needs editing.
    3. Enter the information in the Notes section.
    4. Click Save.
  2. Insurance Company Record
    1. Click Settings > Insurance > Find Insurance Plan.
    2. Look for and open the payer that needs editing.
    3. Enter the information in the Notes section.
    4. Click Save.

Complete Enrollments

All enrollment payer will need to be completed and signed by the practice and approved by the payer before claim submission can begin. This will ensure that the claims will not be rejected for setup information.

Payer Enrollment

Do not submit claims to a payer until you have confirmed claims enrollment is approved if they required.

Follow the instructions in the article to Submit Payer Enrollment Requests.

 

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