Instruction and Guide: Rejected claim and denied claim
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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