Instruction and Guide: Rejected claim and denied claim


Rejected claims are defined as claims with invalid or missing data elements, such as the provider tax identification number, member ID number, that are returned to the provider or EDI* source without registration in the claim processing system.

• Rejected claims are not registered in the claim processing system and can be resubmitted as a new claim.
Denied claims are registered in the claim processing system but do not meet requirements for payment under Plan guidelines. They should be resubmitted as a corrected claim.

• Denied claims must be re-submitted as corrected claims within 180 calendar days from the date of service.
Note: These requirements apply to claims submitted on paper or electronically