Even a well-prepared insurance claim can run into issues. This article explains how to identify and resolve the most common claim problems, including rejections, denials, and missing ERA data.
📍 Note: This article applies to practitioners using the Claim.MD integration. Setting Up Your Claim.MD Integration →
In this article:
- Rejected vs. Denied: Understanding the Difference
- Responding to a Rejected Claim
- Responding to a Denied Claim
- Secondary Insurance Claim Not Being Submitted
- ERA Not Appearing for a Paid Claim
Rejected vs. Denied: Understanding the Difference
These two statuses are easy to confuse, but they require different responses.
Rejected:
- Means the claim never reached the payer. Claim.MD identified a data or formatting error and returned the claim before it was transmitted. Common causes include invalid NPI numbers, missing qualifiers, incorrect zip codes, and invalid Tax IDs. The fix is to correct the claim data and resubmit.
Denied:
- Means the payer received and reviewed the claim but decided not to pay it. The reason varies, and your next step depends on what the ERA says.
| Status | What happened | What to do |
| Rejected | Claim turned away by Claim.MD before reaching the payer. | Correct the data error and resubmit manually. |
| Denied | Claim received and reviewed by the payer; payment not issued. | Review the ERA for the denial reason, then appeal, correct, or update the client's responsibility. |
📍 Note: Practice Better uses "Denied" as a catch-all when insurance pays $0, which includes deductible scenarios. Always check the ERA for the specific reason before taking action.
Responding to a Rejected Claim
When a claim is rejected, the status updates to Rejected in your claims manager.
- Go to My Practice > Insurance Claims and click View to the right of the rejected claim.
- In the right-hand panel, review the Latest Messages section for the rejection reason.
- Open the More Options menu (3 dots) next to the claim and select Edit claim details.
- Make the necessary corrections in the claim editor.
- Update the claim status to Ready to submit and resubmit manually.
📍 Note: Rejected claims do not resubmit automatically. You must update the status and resubmit after making corrections.
Looking Up Rejection Codes
Rejection messages from Claim.MD include error codes that explain what went wrong. You can look up specific rejection codes using the following resources:
- X12 Claim Adjustment Reason Codes → Look up specific rejection or adjustment reason codes by number.
- Claim.MD: How to Handle Rejected Claims → Step-by-step guidance from Claim.MD on resolving rejections.
If you're unsure which field to correct after reviewing the error, contact Claim.MD support → for clarification. You may also need to update fields like your NPI in your Practice Better Insurance Billing settings →
Responding to a Denied Claim
When a claim is denied, the ERA contains the information you need to determine your next step. Go to My Practice > Insurance Claims, click View next to the denied claim, and review the ERA details in the right-hand panel.
Your next step depends on the denial reason:
-
Applied to deductible: The client owes the full or partial balance. Update the Client Responsibility in your claims manager to reflect the amount owed. Learn how to update client responsibility →
-
Non-covered service or missing authorization: You may need to submit a corrected claim or file an appeal directly with the payer. Consider duplicating the original claim as a starting point. Learn how to duplicate a claim →
- $0 paid (catch-all denial): Practice Better uses "Denied" for all outcomes where insurance pays $0, including deductible scenarios. Check the ERA for the specific reason code before deciding how to proceed.
Looking Up Denial Reason Codes
- X12 Claim Adjustment Reason Codes → Look up the reason code from the ERA to understand why the claim was denied.
- Claim.MD: Claim Adjustment Reason Codes → Claim.MD's reference for adjustment reason codes.
- Claim.MD: How to Handle Denied Claims → Guidance from Claim.MD on next steps after a denial.
Secondary Insurance Claim Not Being Submitted
If you added a secondary benefit plan to a claim but don't see a separate claim submitted to the secondary payer, here's why.
📍 Note: Checking Include a secondary benefit plan in the claim editor only populates box 9 (coordination of benefits) on the primary claim. It does not transmit a second claim to the secondary payer.
Practice Better does not have an EOB field, so a secondary claim can't be filed through Practice Better.
To bill the secondary payer:
- Wait for the ERA from the primary payer's claim.
- Log in to your Claim.MD account directly.
- File the secondary claim in Claim.MD, referencing the primary payer's EOB. Claim.MD: How Do I Handle Secondary and Tertiary Claims? →
📍 Note: This step happens entirely in Claim.MD. Practice Better won't reflect the secondary claim's status, since it wasn't submitted through the portal.
ERA Not Appearing for a Paid Claim
If a claim shows as Paid but you're not seeing ERA data, try the following steps:
- Go to My Practice > Insurance Claims.
- Open the More Options menu (3 dots) in the top right of the claims manager and click Update Claims to manually refresh.
- If the ERA still isn't appearing, log into your Claim.MD account directly and review the claim there to cross-reference what information is available.
- If you still don't see the data you're expecting after completing the steps above, contact Practice Better support → with the details of what you've tried.
📍 Note: Manual claim syncing is limited to once per hour.