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 and clearinghouses, open the Insurance Balances tool and visit the Rejected Claims tab.
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 the rejections.
On the Claim Rejections worklist, you can see the date of the rejection, the payer, the patient, the date of service, the number of days since the date of service, the amount on the claim, the claim ID, whether the rejection came from a clearinghouse or the payer, and the reason for the rejection, if available. You can also see a Rejection Status (which defaults to "Unresolved") and whether the rejection is assigned to a user or has been resolved.
You can filter the list to isolate rejections you need to work on. You can choose an age, enter a date range, limit the list to resolved or unresolved rejections, or filter by assignee. You can enter a search term in the Search Filter field to find rejections based on a patient name or claim ID, for example.
You can also sort the list by any column, making it easy to target rejections based on age or the amount on the claim, for example.
If you are certain a rejection or rejections are now 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 might handle a billing problem for an encounter using a different tool, and an encounter's balance may already be paid off. The rejection from the payor remains 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.
The Claim Rejections - View Details screen provides information and tools that will help you review and respond to the rejection.
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Rejection Details: The Rejection Details section indicates when your PCC system received the rejection, the claim ID indicated by the payer, the plan, and the amount on the claim.
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Encounter Details: The Encounter Details section shows the patient, date of service, and how much is currently pending insurance and personal. If the "Insurance Due" amount is now $0.00, the rejection may already be resolved or else your practice may have changed the responsible party for the charges.
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Claim Rejection Change History: Any time anyone at your practice assigns or changes the status of this claim rejection, it is logged in the Claim Rejection Change History.
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Encounter Billing Notes: If you or someone at your practice has entered encounter billing notes (sometimes called "visit billing notes" or "oops notes"), the Encounter Billing Notes section will display those notes. If you’ve contacted the payor and submitted a claim multiple times, you can review your practice’s notes to better understand the history of the rejection.
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Rejection Reason: When your PCC system receives the rejection from the payor or clearinghouse, it attempts to extract a reason summary from the data. That summary is listed on the screen as the "Rejection Reason", and the complete rejection data file is shown so you can review it.
Different payors and clearinghouses send different types of electronic communication. A single file may include responses to many different claims, so the search field of the Rejection Reason 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.
Assign a Rejection to a User or Mark It as Resolved
You can optionally assign a rejection so it can be addressed later by yourself or another person at your practice.
When you are finished addressing a rejection, click "Resolved" to change its status.
PCC EHR tracks whenever a rejection is assigned or resolved and displays a log in the Claim Rejection Change History at the top of the screen.
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 replacement claim, that new rejection (with a new claim ID) will appear on the Rejected Claims worklist. If you mark a rejection as "Resolved" without resubmitting or filing an appeal, your practice may not receive payment. However, your practice can catch claims that slip through the cracks on the Unpaid Encounters tab in the Insurance Balances tool.
View More Encounter Details and the Encounter’s Claim History
After reviewing the rejection, you may want to dig deeper and review charges, payments, and claim history for the encounter. 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 insurance billing activity and includes links to review the payor acknowledgements, posted ERAs, and more.
Review Patient Policies, the Complete Account History, and More
If you need to review more information about the patient and the account, you can navigate to other sections of the chart. For example, after clicking "Billing History", click "Demographics" to review insurance policies.
Or, to see the encounter and all financial transactions for the patient's billing account, visit the 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 an encounter's 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 notes added at the time.
Edit Encounter Details and Submit a New Claim
If you need to edit some aspect of the encounter and then optionally file a new claim, click "Edit Charges".
On the Edit Charges screen, you can change encounter details, diagnoses, procedures, and more.
If you need to file a corrected claim, you can review and adjust the responsible party for each charge, enter claim information, and queue up a new claim.
On the same screen, you can use the Encounter Billing Notes component to add notes or indicate how an issue was resolved.
To learn more, read Edit Encounter Charges and Other Claim Information and Resubmit a Claim.