Rejection vs. Denial — Know the Difference
These two terms are often confused but require different actions:
- Rejection — the claim was refused by the clearinghouse or payer before adjudication because of a formatting or data error (wrong NPI, missing field, invalid date). The claim was never processed. Correct it and resubmit as a new claim.
- Denial — the claim was received and adjudicated but the payer decided not to pay (lack of authorization, non-covered service, timely filing). The claim receives an ERA with a CARC denial code. You may need to appeal or correct and resubmit with frequency code 7.
Finding Rejected Claims in Onvelas
- Go to Billing → Claims.
- Filter by status: Rejected or Denied.
- Open the claim. The Status panel shows the rejection reason or denial CARC code.
- Hover over any CARC code to see the full description and suggested action.
Correcting a Rejected Claim
For clearinghouse rejections (never reached the payer):
- Click Edit Claim to fix the error (wrong date, missing modifier, invalid NPI).
- Resubmit. No frequency code change needed — this is treated as a new original claim.
Submitting a Corrected Claim (Frequency Code 7)
When a claim was accepted and adjudicated but you need to correct billing information:
- Open the original claim and click Create Corrected Claim.
- Onvelas automatically sets the Frequency Code to
7(replacement) and populates the Original Claim Reference Number from the ERA. - Make your corrections — CPT codes, dates, units, modifiers, diagnosis codes.
- Click Submit. The corrected claim is sent as a new 837P with the replacement indicator.
Common Rejection Causes and Fixes
| Error | Fix |
|---|---|
| Invalid NPI | Verify NPI in provider billing profile; confirm 10 digits |
| Missing modifier | Add required HO/HN/HM modifier under line items |
| Authorization not on file | Confirm auth number in claim header; verify payer has the auth |
| DOS not covered by auth | Check auth start/end dates; request retroactive auth from payer |
| Duplicate claim | Confirm original wasn't already paid; use void (frequency code 8) if needed |
| Patient not eligible | Re-run eligibility for the DOS; verify payer ID is correct |
Voiding a Claim
If a claim was paid but should not have been (wrong patient, duplicate payment), submit a void using Frequency Code 8. In Onvelas, click Void Claim from the claim detail — this zeros out charges and notifies the payer to reverse the payment.
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