Documentation Index
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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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