Common claim rejections and denials

This article provides a reference guide for common claim rejections and denials, along with possible solutions.

Overview

Rejection vs. denial

Rejections happen before the payer adjudicates the claim — usually a front-end edit at the clearinghouse or payer that prevents the claim from being accepted. Fix the issues and resubmit the claim from the Claims Queue. See Claims Queue for the rejection-handling workflow. Denials happen after the payer adjudicates the claim and decides not to pay. Review the Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC), correct or appeal as appropriate, and resubmit a corrected claim or appeal. See Managing Denials for the denial-handling workflow.

How to use this guide

Entries are grouped into Front-end rejections and Payer denials, then by category. Scan the section that matches the type of message you’re working, or use your browser’s Find function to search for a specific alert message or CARC:

Windows: Ctrl + F
Mac: Command + F

Billing and coding decisions are best made by you and your team — you know your practice best. This article is simply here to show you what Elation’s billing features can do and how to make the most of them.

Front-end rejections

These messages come back from the clearinghouse or payer’s front-end edits before the claim is adjudicated. Correct the issue in the claim and resubmit through the Claims Queue.

Coding / data

Rejection / denial message	Explanation	Possible solutions
Diagnosis pointer required	No DX codes present	Add diagnosis codes to the claim and rebill
Diagnosis code pointer missing/invalid	Error with DX fields	Confirm diagnosis codes are correct on the claim, ensure there are no more than 12 distinct diagnosis codes on the claim, rebill

Demographics

Rejection / denial message	Explanation	Possible solutions
Invalid address/city/zip	Information mismatch with payer records	Verify address with USPS tool, ensure patient address matches payer records, rebill

Enrollment

Rejection / denial message	Explanation	Possible solutions
Submitter not approved	Not enrolled for electronic claims	Enroll for Claims for the Payer via Settings → Practice Settings → Insurance
Billing NPI not on file	NPI not valid with payer	Enroll for Claims for the Payer via Settings → Practice Settings → Insurance

Workers Comp / Auto

Rejection / denial message	Explanation	Possible solutions
Workers Comp/Auto claim ID required	Claim ID needed	Add the patient’s claim ID to the Auth/Referral Number field in Authorizations; sometimes the Member ID needs to be the patient’s SSN, rebill

Payer denials

These messages come back from the payer after the claim has been adjudicated, usually through an ERA/EOB. For an end-to-end workflow, see Managing Denials in Elation Billing.

Authorization / referral

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO15	Authorization number missing, invalid, or does not apply	Authorization exists but was not transmitted correctly on the claim, or does not match the billed service/provider.	Add the correct authorization number to the claim and resubmit as a corrected claim.
CO197	Pre-certification/authorization/notification/pre-treatment absent	No authorization was obtained before the service was rendered (different from CO15, where auth exists but is missing from claim).	Request retro-authorization if payer allows (often a 24–72 hr window). Otherwise generate an appeal based on medical necessity or emergent circumstances.

Benefit limits

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO119	Benefit maximum for this time period or occurrence has been reached	Patient has hit a benefit cap (visit limit, annual max, lifetime max, or per-occurrence limit) for this service category.	Verify benefit limits with payer. Confirm CPT is correct. If limit shouldn’t apply, file an appeal with documentation. Otherwise transfer balance to patient if plan allows.

Bundled / inclusive

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO97, CO234	Benefit included in another service	Claim bundled or previously processed	Check payer portal, confirm appropriate modifiers used, submit a correct claim if needed.

Capitation

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO24	Payment adjusted - capitation agreement	Claim is covered by a capitation agreement	If fully capitated, settle the capitated claim. If part of the claim is capitated, create a Payment with amount in Allowed field and settle the remainder to capitation. If wrong payer, transfer to correct payer.

Coordination of Benefits / coding

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO16	Lacks information for adjudication	Generalized alert, check Remittance Advice Remark Codes	Look at the ERA/EOB for the claim and review the denial codes, fix issues, submit a corrected claim.
CO16	Missing primary payer adjustment information (CAS segment)	On a secondary claim, the primary payer’s adjustment codes/amounts (CAS segment data) were not populated.	Post the primary payment, populate the Claim Adjustment Segment fields from the primary EOB, and resubmit the secondary claim.

COB / other insurance primary

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO22	This care may be covered by another payer per coordination of benefits	Another payer is expected to be primary; secondary claim is missing primary payer EOB/adjudication data.	Verify payer order. If billed wrong primary, resubmit to correct payer. If secondary, resubmit (don’t appeal) with primary EOB and Claim Adjustment Segment fields data populated.

Coding / medical necessity

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO96, CO204	Non-covered charge	Procedure not covered by payer	Check remittance codes, confirm correct CPT and diagnosis codes were used, submit a corrected claim if needed.

Documentation

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO252	An attachment/other documentation is required to adjudicate this claim/service	Specific documentation is needed; the accompanying RARC identifies what.	Read the paired RARC to identify the required document. Print and mail the claim with documents attached, or file an appeal with documents attached.

Duplicate

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO18 / OA18	Exact duplicate claim/service	Already received by payer. Per X12, code 18 should use group code OA except where state workers’ comp regulations require CO.	No action required if a true duplicate. If submitting a corrected claim, use claim frequency code 7 (replacement) or 8 (void). For separate same-day services, use distinguishing modifiers (59, XE, XS, XP, XU).

Eligibility / coverage

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO31, CO32	Patient cannot be identified as our insured	Patient ID doesn’t match payer records, or patient is not an eligible dependent (CO32). Often means claim went to the wrong payer.	Review eligibility, verify insurance card, contact patient, update payer. Afterwards send the claim to the correct payer or appeal with proof of eligibility.
CO27	Expenses incurred after coverage terminated	Policy is no longer active	Review eligibility, contact patient, update payer. Afterwards send the claim to the correct payer or appeal with proof of eligibility.

Medical necessity

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO50	Non-covered services - not deemed a ‘medical necessity’ by the payer	Service does not meet the payer’s medical necessity criteria (for example, LCD/NCD for Medicare). NOT a contract exclusion — that’s CO96/CO204.	Appeal with clinical documentation that maps to the payer’s medical policy/LCD criteria. Consider peer-to-peer review for high-dollar denials.

Timely filing

Common CARCs	Rejection / denial message	Explanation	Possible solutions
CO29	Time limit for filing expired	Missed timely filing window	If originally filed timely, appeal with claim history. Otherwise, write-off with reason documented.

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Common claim rejections and denials

Overview

Rejection vs. denial

How to use this guide

Front-end rejections

Coding / data

Demographics

Enrollment

Workers Comp / Auto

Payer denials

Authorization / referral

Benefit limits

Bundled / inclusive

Capitation

Coordination of Benefits / coding

COB / other insurance primary

Coding / medical necessity

Documentation

Duplicate

Eligibility / coverage

Medical necessity

Timely filing

​Overview

​Rejection vs. denial

​How to use this guide

​Front-end rejections

​Coding / data

​Demographics

​Enrollment

​Workers Comp / Auto

​Payer denials

​Authorization / referral

​Benefit limits

​Bundled / inclusive

​Capitation

​Coordination of Benefits / coding

​COB / other insurance primary

​Coding / medical necessity

​Documentation

​Duplicate

​Eligibility / coverage

​Medical necessity

​Timely filing

​Related Articles

Overview

Rejection vs. denial

How to use this guide

Front-end rejections

Coding / data

Demographics

Enrollment

Workers Comp / Auto

Payer denials

Authorization / referral

Benefit limits

Bundled / inclusive

Capitation

Coordination of Benefits / coding

COB / other insurance primary

Coding / medical necessity

Documentation

Duplicate

Eligibility / coverage

Medical necessity

Timely filing

Related Articles