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Claim Level Reject at the Provider, Subscriber or Patient Level

We have received the explanation that claim level rejection works as designed in the 2300 Loop of the 837 and does NOT have rejection capability in the Provider, Subscriber and Patient Loops. Based on our competitors’ capabilities and our client needs, we need to be able to reject claims (not entire transactions) for data in the Provider, Subscriber and Patient Loops.

Examples:

  1. An 837P transaction file containing 5000 claims is received, client wants to reject if Subscriber or Patient ID is not valid (not found on file in the database). Only those claim for that Subscriber/Patient should reject and all other claims for other Subscribers/Patients should continue to process and be accepted if there aren't any other failures.

  2. An 837P transaction file containing 5000 claims is received, client wants to reject if the Provider ID is not valid (not found on file in the database). Only those claims for the Provider that fails should reject and all other claims for other Providers continue to process if there aren't any other failures.

Other software vendors have this capability and it is essential for our new clients trying to eliminate other software such as Edifecs.

  • Avatar32.5fb70cce7410889e661286fd7f1897de Guest
  • Mar 6 2020
  • Planned for Future Release
How will this idea be used?

New business to reject claims at the Provider, Subscriber or Patient level.

What is your industry? Healthcare
What is the idea priority? Urgent
DeveloperWorks ID
RTC ID
Link to original RFE
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