Can You Resubmit a Rejected Medical Claim?

A rejected medical claim can generally be corrected and resubmitted, but it is important to understand why the claim was rejected before sending it again.

Unlike a claim that has already been adjudicated, a rejected claim generally did not successfully proceed into adjudication. This distinction affects how the corrected claim should be submitted and whether a claim frequency code such as 1 (Original) or 7 (Replacement) may be appropriate.

This guide explains what to do after a medical claim is rejected, how to identify the rejection reason and what to review before resubmitting the claim.

What Does It Mean When a Medical Claim Is Rejected?

A rejected medical claim is generally a claim that encounters a problem during claim validation, clearinghouse processing or payer claim acceptance that prevents it from successfully proceeding into adjudication.

The rejection indicates that something about the submitted claim needs to be reviewed before the claim can continue through the normal processing workflow.

Depending on where the rejection occurs, the provider may receive information about the problem from a clearinghouse, payer or electronic claim acknowledgment such as a 277CA Health Care Claim Acknowledgment.

Rejected Claims Are Different From Denied Claims

Before resubmitting a claim, make sure the claim was actually rejected rather than denied.

A rejected claim generally did not successfully proceed into adjudication. A denied claim, by comparison, has generally been adjudicated and the payer determined that some or all of the submitted charges would not be paid as billed.

For a complete explanation of this distinction, see our Rejected Claim vs. Denied Claim: What's the Difference? guide.

Should a Rejected Claim Be Resubmitted With Code 1 or Code 7?

This is one of the most important questions to answer before resubmitting a rejected claim.

If the prior submission was rejected before adjudication, the corrected claim is generally resubmitted using Claim Frequency Type Code 1, which identifies an Original Claim.

Claim Frequency Type Code 7, by comparison, identifies a Replacement of Prior Claim and is generally used when a previously adjudicated claim needs to be replaced with corrected claim information.

Important: These are general guidelines. Payers can have specific claim correction and resubmission procedures that should be reviewed before submitting the corrected claim.

Why Is Code 7 Generally Not Used for a Rejected Claim?

Claim Frequency Type Code 7 tells the payer that the new submission is intended to replace a prior claim.

If the earlier submission was rejected before adjudication, there may be no adjudicated payer claim to replace. The provider is instead correcting the problem that prevented the original claim from successfully proceeding into adjudication and resubmitting the corrected claim.

For a detailed explanation of when Code 7 should be used, see our Claim Frequency Type Code 7 - Replacement of Prior Claim Explained guide.

How Do You Find Out Why a Claim Was Rejected?

Before changing and resubmitting the claim, review the acknowledgment or rejection information that was returned for the original submission.

The source of this information can vary depending on the claim submission workflow. Rejection information may be available through:

• a clearinghouse claim report or portal
• a payer claim submission report or portal
• a 277CA Health Care Claim Acknowledgment
• billing or practice-management software that displays returned claim status information

The goal is to identify the specific problem reported for the claim rather than simply making assumptions about why it was rejected.

How the 277CA Can Help Identify a Rejected Claim

The 277CA Health Care Claim Acknowledgment is used in electronic claim processing to communicate claim acknowledgment and status information, including whether claims were accepted or rejected.

When a claim is rejected, the 277CA can include status information that helps identify the problem associated with the claim. This information can help determine what needs to be corrected before the claim is resubmitted.

What Should You Correct Before Resubmitting a Rejected Claim?

The correction should address the specific problem identified in the rejection information. The exact issue can vary considerably from one claim to another.

Examples of information that may need to be reviewed can include:

• patient or subscriber information
• member or identification numbers
• provider identifiers or information
• payer information
• required claim information that is missing
• invalid or inconsistent claim data
• service, diagnosis or other reported claim information
• electronic claim formatting or submission requirements

Steps for Resubmitting a Rejected Medical Claim

A practical resubmission workflow can generally be broken into the following steps:

What Happens After You Resubmit the Claim?

Resubmitting the corrected claim does not by itself mean that the claim has been accepted or will be paid.

The new submission must still pass the applicable claim validation and acceptance processes. If accepted, it can then proceed into adjudication, where the payer evaluates the claim according to the patient's coverage, payer policies and other applicable requirements.

Can a Resubmitted Claim Be Rejected Again?

Yes. A resubmitted claim can be rejected again if the original problem was not fully corrected or if another validation issue is identified during processing.

For example, correcting one invalid field does not guarantee that another issue will not be identified when the claim is processed again.

If the resubmitted claim is rejected, review the newest rejection information rather than assuming it is the same problem reported previously.

What About Timely Filing?

A rejected claim should generally be corrected and resubmitted promptly. A rejection does not necessarily mean that timely-filing requirements no longer apply or that the provider automatically receives additional time to submit the corrected claim.

Timely-filing rules and the treatment of previously rejected submissions can vary by payer and contract. If a claim is approaching a filing deadline, review the payer's current requirements and any available documentation showing when the original submission was made.

Rejected Claim Resubmission Examples

Example 1: Invalid Subscriber Information

A provider submits an original claim, but the claim is rejected because subscriber information reported on the claim is invalid.

Typical action: Review the rejection details, correct the subscriber information and generally resubmit the claim as an Original Claim using Code 1, subject to payer-specific requirements.

Example 2: Missing Required Claim Information

A claim is rejected because required information is missing from the submission.

Typical action: Determine what information was reported as missing, complete the claim and resubmit it according to the payer's requirements.

Example 3: Claim Was Actually Adjudicated

A provider initially believes a claim was rejected but discovers that the payer had already adjudicated the claim. Information reported on the adjudicated claim now needs to be corrected.

Typical action: Do not assume the claim should simply be resubmitted as another original claim. Review whether the payer requires a Replacement Claim using Code 7.

Example 4: Claim Was Denied, Not Rejected

A payer adjudicates a claim but does not approve a service for payment. The provider initially refers to the claim as "rejected."

Typical action: Review the actual denial and adjustment information before resubmitting anything. Depending on the reason, the appropriate response could involve a corrected/replacement claim, additional documentation, reconsideration, appeal or another payer-specific process.

Common Mistakes When Resubmitting Rejected Claims

Rejected Claims vs. Corrected and Replacement Claims

A rejected claim can certainly contain information that needs to be corrected, but that does not automatically make the new submission a Claim Frequency Type Code 7 replacement claim.

The key distinction is what happened to the prior submission:

• Rejected before adjudication: correct the rejection and generally resubmit as an Original Claim using Code 1.
• Adjudicated claim with incorrect information: review whether the payer requires a Replacement Claim using Code 7.
• Adjudicated claim that should be canceled: review whether the payer requires a Void/Cancel Claim using Code 8.
• Adjudicated claim where the submitted information was correct but the decision is disputed: review the payer's reconsideration or appeal process.

Frequently Asked Questions

Important: Claim rejection, correction and resubmission requirements can vary by payer, clearinghouse, health plan and program. The information in this guide provides a general overview and should be used together with the payer's current billing and submission requirements.

For technical requirements related to electronic professional claim submissions using the X12 837P transaction, refer to the official implementation guides published by X12.