Rejecting a Request

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When you click the 'Reject' button you will be confronted with the Response: Reject Eligibility Benefit Inquiry screen:

 

Rejection

The Reject screen

 

You can see in the left upper part of the screen an options menu.  Here you have to choose at which level the request is to be rejected. Accordingly, the Reject Reasons will be available.  Each level has different reject reasons. The most likely reason to reject is that the provider is not in the network or the subscriber/patient is not on file.

 

Top Level:Required when the request could not be processed at a system or application level based on the entities identified in ISA06, ISA08, GS02 or GS03 and to indicate what action the originator of the request transaction should take.  Below are valid reject reasons for Top level rejections

 04 Authorized Quantity Exceeded

 41 Authorization/Access Restrictions

 42 Unable to Respond at Current Time

 79 Invalid Participant Identification

 

Insurance Level:Required when the request could not be processed at a system or application level when specifically related to the information source data contained in the original 270 transaction’s information source name loop (Loop 2100A). it also indicates that the information source itself is experiencing system problems and to indicate what action the originator of the request transaction should take. Below are the valid reject reasons for an insurance level rejection

 04 Authorized Quantity Exceeded

 41 Authorization/Access Restrictions

 42 Unable to Respond at Current Time

 79 Invalid Participant Identification

 80 No Response received - Transaction Terminated

 T4 Payer Name or Identifier Missing

 

Provider Level:Required when the request could not be processed at a system or application level when specifically related to the information receiver data contained in the original 270 transaction’s information receiver name loop (Loop 2100B) and to indicate what action the originator of the request transaction should take. Below are the valid reject reasons for an provider level rejection

 15 Required application data missing

 41 Authorization/Access Restrictions

 43 Invalid/Missing Provider Identification

 44 Invalid/Missing Provider Name

 45 Invalid/Missing Provider Specialty

 46 Invalid/Missing Provider Phone Number

 47 Invalid/Missing Provider State

 48 Invalid/Missing Referring Provider Identification Number

 50 Provider Ineligible for Inquiries

 51 Provider Not on File

 79 Invalid Participant Identification

 97 Invalid or Missing Provider Address

 T4 Payer Name or Identifier Missing

 

Subscriber or Dependent Level:Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction’s subscriber name loop (Loop 2100C) and to indicate what action the originator of the request transaction should take.

 15 Required application data missing

 35 Out of Network

 42 Unable to Respond at Current Time

 43 Invalid/Missing Provider Identification

 45 Invalid/Missing Provider Specialty

 47 Invalid/Missing Provider State

 48 Invalid/Missing Referring Provider Identification Number

 49 Provider is Not Primary Care Physician

 51 Provider Not on File

 52 Service Dates Not Within Provider Plan Enrollment

 56 Inappropriate Date

 57 Invalid/Missing Date(s) of Service

 58 Invalid/Missing Date-of-Birth

 60 Date of Birth Follows Date(s) of Service

 61 Date of Death Precedes Date(s) of Service

 62 Date of Service Not Within Allowable Inquiry Period

 63 Date of Service in Future

 71 Patient Birth Date Does Not Match That for the Patient on the Database

 72 Invalid/Missing Subscriber/Insured ID

 73 Invalid/Missing Subscriber/Insured Name

 74 Invalid/Missing Subscriber/Insured Gender Code

 75 Subscriber/Insured Not Found

 76 Duplicate Subscriber/Insured ID Number

 78 Subscriber/Insured Not in Group/Plan Identified

 

Subscriber or Dependent Benefit Level:Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction’s dependent name loop (Loop 2100D) and to indicate what action the originator of the request transaction should take.

 15 Required application data missing

 35 Out of Network

 42 Unable to Respond at Current Time

 43 Invalid/Missing Provider Identification

 45 Invalid/Missing Provider Specialty

 47 Invalid/Missing Provider State

 48 Invalid/Missing Referring Provider Identification Number

 49 Provider is Not Primary Care Physician

 51 Provider Not on File

 52 Service Dates Not Within Provider Plan Enrollment

 56 Inappropriate Date

 57 Invalid/Missing Date(s) of Service

 58 Invalid/Missing Date-of-Birth

 60 Date of Birth Follows Date(s) of Service

 61 Date of Death Precedes Date(s) of Service

 62 Date of Service Not Within Allowable Inquiry Period

 63 Date of Service in Future

 64 Invalid/Missing Patient ID

 65 Invalid/Missing Patient Name

 66 Invalid/Missing Patient Gender Code

 67 Patient Not Found

 68 Duplicate Patient ID Number

 71 Patient Birth Date Does Not Match That for the Patient on the Database

 77 Subscriber Found, Patient Not Found

 

When you select Subscriber or Patient Benefit Level, drop down box appears that lets you select which benefit line is rejected.

BenefitLevelRejection

The drop-down box that let's you choose the benefit line of the request.

 

According to the reject reason select a meaningful follow-up code. There are:

 C Please Correct and Resubmit

 N Resubmission Not Allowed

 R Resubmission Allowed (Use only when AAA03 is “42".)

 S Do Not Resubmit; Inquiry Initiated to a Third Party

 W Please Wait 30 Days and Resubmit

 X Please Wait 10 Days and Resubmit

 Y Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly (Use only when AAA03 is “42".)

 

Once you are done, click on the 'Save' button and return to the request screen.