As part of claim processing, claims go through three separate reviews before reaching a payer’s internal adjudication system. You may receive electronic claim rejections from one or more of these reviewers: Kareo PM, clearinghouse or the payer.
These reviews check for correct claim formatting rules (i.e.: patient address, service location, diagnosis/procedure codes, payer ID etc). If there is missing or invalid information, your claim is prevented from being forwarded on to the next reviewer. When this occurs, a rejection report is generated and you must review the reason for the rejection, make the correction and resubmit the claim.
Once the claim passes through all three reviews for correct information, your claim will go on to the payer’s adjudication system. The payer then reviews the claim based on the patient’s insurance plan coverage and the contract it has with the provider; any claim denials at this stage are reported to you via an Electronic Remittance Advice (or Explanation of Benefits). If you are looking for instructions on how to resolve claim denials, please refer to the Payment Posting guide.