Overview

A rejected claim was returned before the payer processed it, usually because information on the claim is missing, invalid, or doesn't match the payer's records.

Find the rejection message on your claim, then use this article to learn what it means and how to fix it.

There are two kinds of rejections:

Clearinghouse rejections: The clearinghouse rejected the claim before forwarding it to the payer.
Payer rejections: The payer rejected the claim for missing or invalid information before processing it.

After you fix the cause of a rejection, resubmit the claim.

To see all of your rejected claims in one place, use the Claim Rejections Report.

Note: A rejection is different from a denial. A rejected claim was never processed, so you can correct it and resubmit it. A denied claim was processed by the payer, and the payer decided not to pay it. For a denial, review the remittance advice and contact the payer.

Important: Rejection messages are often long. To find yours quickly, search this page for a few words from the message (press Ctrl+F on Windows or Command+F on Mac).

Rejection Reasons

Patient and Subscriber Information

Subscriber and Subscriber ID Mismatched

Rejection Message	Subscriber and Subscriber ID mismatched.
Cause	This rejection has three possible causes: The claim was submitted to the wrong payer ID. The patient's demographics or insurance policy on the claim weren't eligible for the date of service billed. The patient was recently added to the insurance policy, and the payer's records aren't current yet.
Resolution	Depending on the cause: If the claim was submitted to the wrong payer ID, verify the payer information and resubmit the claim. If the patient's demographics or policy information are incorrect, update them and resubmit the claim. If the information is correct, contact the payer to verify the patient's coverage for the date of service.

Entity's Name Rejection

Rejection Message	Entity's Name
Cause	This rejection has three possible causes: The claim was submitted to the wrong payer ID. The patient's demographics or insurance policy on the claim weren't eligible for the date of service billed. The patient was recently added to the insurance policy, and the payer's records aren't current yet.
Resolution	If the claim was submitted to the wrong payer ID, verify the payer information and resubmit the claim to the correct payer. If the patient's demographics or policy information are incorrect, correct the patient's insurance details and resubmit. If the information is correct, contact the payer to verify the patient's coverage.

Entity's Postal / Zip Code Rejection

Rejection Message	Entity's Postal/Zip Code invalid
Cause	Most payers require the full 9-digit ZIP code for addresses on electronic claims. This rejection usually means a ZIP code on the claim is missing the 4-digit extension or is invalid.
Resolution	Check the ZIP code, including the 4-digit extension, for each of these addresses: Provider Subscriber address Insured address Service location Correct any ZIP code that is incomplete or invalid, then resubmit the claim.

Provider Registration and Enrollment

Billing NPI Is Not on File

Rejection Message	You may see any of these messages: BILLING NPI IS NOT ON FILE ...STATUS ENTITY'S NATIONAL PROVIDER IDENTIFIER (NPI). USAGE THIS CODE REQUIRES USE OF AN ENTITY CODE. ...ordering provider NPI must be... registered... If not, the claim will be rejected.
Cause	The NPI or Tax ID (TIN) on the claim isn't registered with the payer. Some versions of this message name the ordering or referring provider instead of the billing provider.
Resolution	Follow these steps: Contact the payer to confirm that your NPI is registered with them. If the message names the ordering or referring provider, confirm that provider's enrollment with the payer. If the payer confirms you're registered, contact Support at Support@NikoHealth.com with the invoice ID so we can investigate further.

Billing NPI Not Registered or Address Mismatch

Rejection Message	You may see any of these messages: Billing NPI is not registered or the submitted data including full 9 digit zip code for the Billing Provider and/or the Service Facility does not match the registered data with the payer. Unable to validate the Billing Provider identifier submitted on the claim.
Cause	The payer doesn't have your Billing Provider NPI on file for electronic claims, or the addresses on the claim don't match the payer's records.
Resolution	Follow these steps: Contact the payer's credentialing or provider enrollment department to confirm that your Billing Provider NPI is registered and active. Check that the Billing Provider address and the Service Facility address on the claim, including the full 9-digit ZIP code, match the payer's records. If you need to start or update enrollment for electronic claims, email payerenrollment@nikohealth.com with the payer name and payer ID. After the payer confirms your NPI is active, resubmit the claim. For more about enrollment, see Clearinghouse Payer Enrollments.

Tax ID and NPI Mismatch

Rejection Message	You may see any of these messages: The Billing Provider Tax Identification (ID) Number does not match the Billing Provider National Provider Identifier (NPI)... BILLING NPI IS NOT AUTHORIZED FOR TAX ID
Cause	The Tax ID and NPI on the claim aren't linked in the payer's system. This is usually a provider enrollment issue with the payer, for example the NPI was never linked to the Tax ID, or a recent change hasn't been updated.
Resolution	Follow these steps: Contact the payer to verify that your Billing Provider NPI and Tax ID match in their records. If you need enrollment help, email payerenrollment@nikohealth.com with the payer name, payer ID, and every NPI that needs to be enrolled. The enrollment team will start the enrollment and send you anything you need to complete. After the payer confirms the information matches, resubmit the claim. For more about enrollment, see Clearinghouse Payer Enrollments.

Service Facility or Billing Address Outside the Payer's Service Area

Rejection Message	Claims with Service Facility Location/Billing Address not in TN, or Not in TN and outside Overlapping Service Area (OSA) must be Filed to Local Plan.
Cause	The service facility location or billing address on the claim is outside the plan's service area. For example, a claim sent to BCBS of Tennessee with a Texas service facility address. The state in the message depends on the plan.
Resolution	Follow these steps: Confirm that you're submitting to the correct state or regional plan for where the services were provided. Open the invoice and check the Service Facility Location and Billing Provider Address. Correct either one if it's wrong. If the patient's coverage is through a different regional plan, add a plan to the payer with the correct regional Payer ID, assign it to the patient's insurance, and resubmit the claim. For help setting up payer plans, see Adding and Configuring Payer Details.

Procedure Codes, Modifiers, and Diagnosis Codes

HCPCS Procedure Code or Modifier Is Invalid

Rejection Message	You may see any of these messages: HCPCS Procedure Code is invalid in Professional Service Claim has invalid information and has been rejected. HCPCS ...HAS BEEN REJECTED. PROCEDURE CODE MODIFIER(S) FOR SERVICE(S) RENDERED. PROCEDURE CODE [code] IS INVALID FOR PAYER. Modifier code [modifier] is not allowed with procedure code [code].
Cause	Either a HCPCS code on the claim isn't valid for the date of service or the payer, or the combination of HCPCS code and modifiers is wrong.
Resolution	Follow these steps: Check the date of service on the claim. Check that each HCPCS code is valid and billable for the payer (for Medicare, DME Medicare) on that date of service. If the codes are valid, check the modifiers. You can use the Advanced Modifier Engine or contact your DME MAC jurisdiction for help. To correct the claim, open the invoice, click the blue + button, and select Modify. Update the code or modifiers and save. Resubmit the claim.

Procedure Code Doesn't Match the Diagnosis (NCD)

Rejection Message	INCORRECT PROCEDURE CODE [code] FOR DIAGNOSIS PER NCD.
Cause	The diagnosis codes on the claim don't support the HCPCS code under Medicare's National Coverage Determination (NCD) for that item.
Resolution	Follow these steps: Open the invoice, click the blue + button, and select Modify. Check that the diagnosis codes meet the coverage policy for the item billed. If you're not sure which diagnosis codes are covered, check the LCD or NCD for that HCPCS code, or contact your DME MAC jurisdiction. Update the diagnosis codes if needed and save. Resubmit the claim.

Secondary Claims and Coordination of Benefits

COB Amount Is Missing or Invalid

Rejection Message	COB Amount is missing or invalid
Cause	The claim is being submitted to a secondary payer, and the primary payer's payments or adjustments (coordination of benefits, or COB) haven't been entered or are incorrect.
Resolution	Follow these steps: Enter the primary payer's response to the claim, including any payments and adjustments. Resubmit the claim to the secondary payer.

Insurance Type Code Missing

Rejection Message	You may see either of these messages: Claim is missing information and has been rejected. Insurance Type Code. ELEMENT SBR05 IS MISSING. IT IS REQUIRED WHEN SBR01 IS NOT ‘P’ AND PAYER IS MEDICARE.
Cause	Medicare is the secondary insurance and the Insurance Type Code is blank. The Insurance Type Code tells Medicare why it isn't the primary payer (for example, the patient has employer group health coverage as primary). Medicare requires it on secondary claims. This rejection applies only when Medicare is secondary.
Resolution	Add the code to the patient's Medicare insurance, then update the invoice so it uses the corrected insurance. In the patient's profile, click the Insurance tab. Click the pencil icon on the Medicare insurance. In the patient section, select the Insurance Type Code that explains why Medicare is secondary. Click Save. Open the invoice and click its Insurance tab. On the Medicare insurance, click Update from patient. Resubmit the claim. Important: Changing the patient's insurance doesn't change invoices that already exist. If you skip Update from patient, the claim is resubmitted without the code and is rejected again.

Payer Doesn't Accept Electronic Secondary Claims

Rejection Message	Payer responsibility sequence number code (loop 2000B, SBR01) must equal P.
Cause	This payer only accepts electronic claims when it is the primary payer. (The "P" in the message means primary.) Secondary and tertiary claims can't be sent to this payer electronically. Mutual of Omaha is a common example.
Resolution	If the patient has a crossover policy, the secondary claim should cross over automatically from the primary payer (for example, Medicare) after the primary claim is processed. If the claim didn't cross over, contact the payer and ask how they want the secondary claim submitted. They may require a paper claim, a portal submission, or another process. For Mutual of Omaha, submit the secondary claim on paper.

Corrected Claims

Payer Assigned Control Number

Rejection Message	PAYER ASSIGNED CONTROL NUMBER.
Cause	The claim was sent as a corrected or replacement claim, but the payer's original claim reference number is missing or doesn't match the payer's records. The payer needs this number to know which claim is being replaced.
Resolution	Follow these steps: Find the payer's original claim control number (also called the ICN or claim reference number). It's on the original EOB or ERA, or you can get it by checking claim status with the payer. Open the invoice, click the blue + button, and select Modify. In the claim resubmission section, set Resubmission Code to Replacement of Prior Invoice. Enter the payer's original claim control number in Original Reference Number. Save the invoice and resubmit the claim.

Workers' Compensation Claims

Carrier Case Number Failed B & E Lookup (Jopari)

Rejection Message	Claim failed submission because Carrier Case Number failed B & E lookup.
Cause	The Workers' Compensation claim number on the invoice couldn't be matched to an active case in the payer's system. The claim number may be missing or incorrect, the payer may not have registered the case yet, or the payer may have an internal matching issue.
Resolution	Follow these steps: Verify the Workers' Compensation claim number with the payer and correct it on the invoice if needed. If you don't have a claim number, enter UNKNOWN in the claim number field. Some payers will process the claim while they resolve the case lookup. Make sure the accident and injury information is filled in on the patient's Insurance tab. Workers' Compensation claims require it. Resubmit the claim. If it's rejected again, contact Support at Support@NikoHealth.com with the invoice ID, and we'll open a case with the clearinghouse.

Unable to Find or Read Documentation (Carisk)

Rejection Message	Unable to find/read documentation.
Cause	The claim was submitted without the required supporting documents, the documents couldn't be read, or the claim was sent to the wrong Workers' Compensation clearinghouse. Some Workers' Compensation payers use Carisk and others use Jopari.
Resolution	Follow these steps: Make sure the supporting document (for example, the prescription or referral) is uploaded to the patient's documents. Open the invoice, click the blue + button, and select Modify. In Supplemental Information (upper right of the invoice), enter the required fields, set Transmission Code to Electronically Only, and select the document. Save the invoice. Contact the Workers' Compensation payer to confirm which clearinghouse to use (Carisk or Jopari), and check that the payer's clearinghouse setting matches. Resubmit the claim.

General Clearinghouse Rejections

Rejected at Clearinghouse for HIPAA Compliance

Rejection Message	REJECTED AT CLEARINGHOUSE FOR HIPAA COMPLIANCE.
Cause	Something on the claim doesn't meet HIPAA electronic claim standards, so the clearinghouse couldn't forward it to the payer. This is a general error. Common causes include: Missing or invalid subscriber information (name, ID, or date of birth) A missing or mismatched payer ID Missing or invalid provider information (NPI, Tax ID, or address) Missing required fields, such as diagnosis codes, ZIP+4 codes, or place of service
Resolution	Check the claim for the common causes above. If you can't find the problem, contact Support at Support@NikoHealth.com with the invoice ID. We'll get the detailed error from the clearinghouse, which tells you exactly which field to correct.

Payer Notices

Final/Denial - For More Detailed Information, See Remittance Advice

Rejection Message	Final/Denial - For More Detailed Information, See Remittance Advice
Cause	This isn't a rejection you can fix and resubmit. It notifies you that the payer is denying the claim.
Resolution	There are no steps to take in NikoHealth. Review the remittance advice when you receive it, and contact the payer for more information.

Troubleshooting Claim Rejections