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eClaims - Common Rejections - Provider Enrollment Rejections

The wording of enrollment rejections can vary greatly from payer to payer. Enrollment rejections include, but are not limited to the following:

  • ACKNOWLEDGEMENT / REJECTED^Submitter not approved for electronic claim submissions on behalf of this entity^Billing Provider
  • ACKNOWLEDGEMENT / REJECTED^Entity's National Provider Identifier (NPI)^Billing Provider
  • ACKNOWLEDGEMENT / REJECTED^Entity's tax id.^Billing Provider
  • Payer/Trading Partner REJ Payer Response ACKNOWLEDGEMENT/REJECTED FOR INVALID INFORMATION^Entity's National Provider Identifier (NPI)^Rendering Provider
  • MISS INFO - ENTITYS CREDENTIAL/ENROLLMENT INFORMATION. USAGE- THIS CODE REQUIRES USE OF AN ENTITY CODE. - RENDERING PROVIDER

These are almost exclusively payer rejections, as the clearinghouse does not check the validity of provider or office information before passing the claim off to the payer.

These types of rejections are considered enrollment rejections. An enrollment rejection means that one or more items that identify either the office or the rendering provider do not match what the payer has on file for them.

Before a provider or office can submit any claims to a payer, whether electronic or paper claims, the providers in the office must credential with the payer. This means that each provider must fill out the paperwork to be on file with each specific payer to submit claims.

At the time a provider credentials with a payer, it is determined exactly how the provider is going to bill that payer. The NPI and Tax ID that will be used to bill is determined at this time. The name and address of the billing entity (whether the office or the individual provider) will also be determined at this time.

If the information that the payer has on file for the office or provider does not line up perfectly, a claim submitted to the payer will reject with an enrollment rejection.

Items to double check when receiving an enrollment rejection
Is the proper billing method being used to send claims for the provider?
One of the most common reasons for this type of rejection, is a result of the provider being on file to either bill under the group or bill as individual and the setting for such somehow being altered within MacPractice. If a provider is on file with the payer to bill as group, any claim sent to this payer where the provider is set to bill as individual, the claim will reject, because individual provider information is populating the section of the claim where the office's information should be.

Conversely, if a provider is on file to bill as individual with the payer, but the office also has a group NPI, if that NPI is entered within MacPractice, but the provider is not set to bill as individual for this payer, the claim will reject, because the office information will populate the section of the claim where the individual provider information is expected.

Has the provider's or the office's information changed at all?
If the office or provider is assigned a new NPI or has changed the Tax ID with which they bill, for whatever reason, it is important that this new information be updated with all payers to which claims are submitted. If the office has moved or changed names, this information as well needs to be updated with all payers to which claims are submitted. If the information is updated in MacPractice, but hasn't been updated at the payers, this will cause claims to receive enrollment rejections. 

Does the payer require recertification?
Some payers require that offices and providers periodically obtain a recertification from them. It may be that the time for recertification has occurred and the notification from the payer was somehow missed or not received by the office. When this occurs, all claims to that payer from the provider or office that requires recertification will receive enrollment rejections.

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