Work on Rejected Claims
If unaddressed, rejected claims result in lost revenue. Use the Rejected Claims worklist to review and respond to every claim rejection sent to your practice.
Draft Documentation: This article describes functionality in PCC 10.4, coming to pediatric practices in late 2025.
Contents
Open and Review the Claim Rejections Worklist
To review claim rejections sent to your practice from payors, open the Rejected Claims worklist in the Insurance Balances tool.
The Claim Rejections Overview summarizes unaddressed rejections sent to your practice. Totals are aged and shown for each insurance group.
Double-click on a single insurance group or click “Work With All” to view all rejection messages.
On the Claim Rejections worklist, you can see… (columns explained).
You can filter the list to isolate rejections you need to work on. For example… (most prominent example, with screenshots).
You can also filter by (assignee? or use column sort).
If you are certain a rejection or rejections are resolved, you can select them and click “Mark as Resolved”.
By reviewing and resolving every claim rejection sent to your practice, you can ensure that no claims slip through the cracks.
Each Rejection is a Message: Rejections are similar to e-mail messages or other incoming communication. Your practice can deal with a billing problem for an encounter somewhere else, and encounter balances may already be paid off. The rejection message from the payor will remain on the Rejected Claims worklist for your review until you mark it as resolved.
Troubleshoot a Specific Rejection
Double-click on a rejection to review more details.
On the Claim Rejections – View Details screen, you can see…/provides information and tools that will help you review and respond to the rejection.
The BLANK section summarizes…
Beneath the rejection details and status, you can review the Encounter Billing Notes for the encounter associated with this rejection. For example, if you’ve contacted the payor and submitted a claim multiple times, you can review your practice’s notes.
Below the Encounter Billing Notes, you can see the rejection reason summary and the full, original rejection file as sent by the payor.
Different payors and clearinghouses send different types of electronic communication. The file may include payor responses to many different claims, so the search field is automatically filled with the Claim ID, making it easier to navigate the electronic file from the payor. If the claim ID appears multiple times in the electronic file, you can use the Find field’s next and previous buttons to review the details.
Review Encounter Details and the Encounter’s Claim History
After reviewing the rejection, click “Billing History” to review more encounter details.
On the Billing History for the encounter, you can review full charge and payment details. The Claim History shows you all billing activity and includes links to review payor acknowledgements and posted ERAs.
Review Patient Policies, the Complete Account History, and More
To review more information about the patient and the account, you can navigate to other sections of the chart. After clicking “Billing History”, click Patient Demographics to review insurance policies.
Or, to see the encounter in the context of other encounters for the family, click “Account History”.
By reviewing the full account history, you can see every event linked to each encounter and also understand the encounter in the context of the family’s billing record.
Review Eligibility for the Encounter’s Date of Service
If you want to check if there are eligibility records for the date of service, click “Edit Charges” and then “Patient Details” to see the eligibility component for that encounter.
If your practice confirmed eligibility for the patient, either automatically or manually, you can review the results and any comments added at the time.
Edit Encounter Details and Submit a New Claim
If you need to edit some aspect of the encounter or file a new claim, click “Edit Charges”.
You can change diagnosis and charge details, the responsibility party for each charge, and more.
After making changes, you can queue up a new claim. You can simultaneously add an Encounter Billing Note explaining what occurred.
Use the Encounter Billing Notes component to add notes about the rejection or indicate how it was resolved.
Resolve the Rejection or Assign It To a User
When you are finished addressing the rejection message, click “Resolved” to change its status.
You can optionally assign a rejection so it can be addressed later by yourself or another person at your practice.
What About Another Rejection?: Marking a rejection message as resolved does not guarantee payment. If you queued up a new claim, it will be processed and submitted when your practice next runs claims. If the payor rejects the claim again, that rejection (with a new claim ID) will appear on the Rejected Claims worklist. If you resolve a rejection without resubmitting or filing an appeal, your practice may not receive payment.