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Fixing claims

Claims fail in two very different ways, and the fix differs accordingly. Everything that needs your attention is surfaced in the Needs Attention card on the Insurance hub.

In this guide, we'll cover:

Rejections (stopped before processing)​

A rejection means the claim never made it into the payer's adjudication system — the clearinghouse or the payer's front door bounced it, usually for a data problem: an identifier mismatch, a malformed member ID, a missing element. Rejected claims are not on file with the payer.

  1. Open the claim. It opens on its Claim form, and above it a short note says who rejected it, when, and why. "Stedi, the clearinghouse, rejected this claim" means Stedi's checks stopped it before the payer saw it; Stedi's suggested fix, when it gives one, is under the reason. Every acknowledgment the claim received, older ones included, is listed on the History tab. See all reasons sorts the reasons into categories (Insurance Information, Patient Demographics, Diagnosis & Billing Codes, Provider / Billing Info, Coverage & Benefits, or Timely Filing), each with step-by-step guidance.
  2. Click Create Corrected Claim, the one button at the top. The Claim form switches to correction mode, and the boxes the payer's reasons point at are framed in orange (when the payer gave no reason, nothing is framed: check the member ID, the payer and the relationship first). A few reasons frame more than the box they name. When the payer couldn't find the member, the name, date of birth and member ID are all framed (and the policyholder's, for a dependent), because any one of them can be off. When it says the policy wasn't active on the date of service, the payer, member ID and group number are framed, not the date. When it says the submitter isn't approved for electronic claims, that's payer enrollment, not the claim: check the payer in Settings → Payer Enrollment, and that Box 33a is the NPI the enrollment names. Correct them right on the form: member ID (1a), referring provider (17), diagnoses (21), prior authorization (23), the service lines (24: date, place of service, CPT, modifiers, diagnosis pointers, rate, units) and accept assignment (27). Box 22 is preset to Original, because the payer never processed the first attempt. Nothing is saved yet; Cancel leaves the claim exactly as it was.
  3. Click Create Corrected Claim… and confirm. The corrected copy is created as a Prepared claim with your edits and the old claim is archived (it stays on file with its last status). You land on the copy; click Submit to Payer — it goes out as a fresh claim, not a duplicate. Filing the copy on paper or another portal instead? Open the arrow next to Submit to Payer and choose Mark as Filed Externally.

The form is drawn like the paper CMS-1500, box for box, so a payer's note about "Box 24D" or "the subscriber's address" points at something you can see. Any Prepared claim can be edited the same way: open it (it opens on the Claim form with its boxes unlocked), type, then Save. Diagnoses (21) are picked from the ICD-10 list by code or name, the same list the treatment plan uses; a code the list does not carry can still be typed and used as is. Changing a diagnosis here changes this claim only; the client's treatment plan is where the next claim reads it from. The client and insurance boxes are typed on the form too, and saved where they live, so the next claim is right as well: member ID (1a), relationship (6) and group number (11) go to the client's insurance plan; the client's name, birth date, sex, address and phone (2, 3, 5) go to the client's profile; and when a spouse or parent holds the plan, their name, address and birth date (4, 7, 11a) go to the policyholder's record. When a change touches the client's record, a confirmation lists each change with the old and new value before anything is saved; the electronic claim is built from the record, so saving there is what sends the correction to the payer. To bill under a spouse or parent, add the policyholder on the client's Payment & Insurance tab first. The practice boxes (25, 31–33) come from Settings.

Denials (processed and refused)​

A denial means the payer adjudicated the claim and decided not to pay — no coverage on the date of service, no authorization, non-covered service, timely-filing, etc. Denials come with reason codes on the ERA/EOB.

The reason code (for example CO-16, "missing information") often says only that something is wrong. The payer's remark codes say what: N290 is the rendering provider's NPI, N822 a missing modifier. See all reasons lists them with the claim line they're about ("Line 2: N822: Missing procedure modifier(s)."), and that line is framed on the claim form. Remarks that are just information (appeal rights, "forwarded to the secondary insurer") show under Payer notes.

  • If the denial is due to incorrect information, click Create Corrected Claim. The claim form opens in correction mode with the boxes the payer's reasons point at framed in orange (See all reasons above the form lists them with their codes). Box 22 is preset to Resubmission (7) with the payer's claim number filled in, so the payer processes it as a correction rather than a duplicate. (It is preset to Original (1) when the payer wants a fresh claim: Medicare always does, and so does a payer that has never seen the claim.) Make the fixes, click Create Corrected Claim and confirm: the copy is created as a Prepared claim with your edits and the original is archived (it stays on file with its last status and an Archived label, links to the corrected claim, and no longer counts as open). Then Submit to Payer on the copy
  • If you disagree with the decision, that's an appeal — filed with the payer per their appeal process, with supporting documentation
  • If the denial says deductible, that's not a true denial — the balance moves to the client (Balances & Deductibles)

When the payer's records differ from yours​

A payer's payment report sometimes says what it has on file. When that differs from the claim, a blue note From the payer's payment report appears above the claim form:

  • A different member ID. Click Use this to copy it onto the client's insurance plan, then correct and resubmit the claim. Nothing changes until you click.
  • A different name. Check it against the insurance card; the payer matches on the name exactly.
  • Another plan is primary. Bill that plan first, then this one as secondary.
  • Forwarded to another plan. The payer sent the claim on to the secondary plan itself, so don't bill that plan for it yourself.

Claim sent to the wrong payer​

Fix the client's coverage so the right plan is Primary, then open the claim and click Create Corrected Claim. The claim page notices the mismatch and walks you through it: the claim sent to the wrong payer is archived, and the copy is billed to the current primary plan as an Original claim, because that payer has never seen it. No void is needed. Only if the wrong payer must cancel the claim on their side, for example because they paid it, void it with them instead (below).

Create Corrected Claim is available on any claim the clearinghouse has taken, whether it is still in flight or already Paid, Denied, Deductible or Rejected. Archived claims keep their last status, show an Archived label, and are left out of Needs Attention and the pending totals. They don't take payments or write-offs: record those on the corrected claim. The Claims list hides archived claims while Hide archived is on (the default); turn it off, or pick Archived in the status filter, to see them.

Voiding a claim​

To retract a claim that shouldn't have been filed at all (wrong client, wrong payer, duplicate, service never happened), open the claim and click Void Claim. The void goes to the payer as a frequency-code-8 claim quoting the payer's claim number, which fills in from the payer's acknowledgment or remittance when Practice Harbor has it. Voiding tells the payer to cancel the claim; the appointment returns to your control so you can rebill it correctly or leave it self-pay.

Void Claim is available on any claim the payer has received, whether it is still in flight (Submitted, Accepted, In review) or already processed (Paid, Denied, Deductible). It is not offered on a draft (nothing was sent), a rejected claim (the clearinghouse bounced it, so the payer never saw it), or a claim filed through another clearinghouse (void it there).

A paid claim. If an insurance payment is posted against the claim, Void Claim asks you to delete or adjust that payment first, so the void cannot leave money attached to a cancelled claim. After the payer accepts the void, it usually takes the money back on a later ERA; see When a payer takes money back.

A claim that went to the wrong payer. Fix the client's insurance first, then open the claim: it shows a Payer Mismatch panel that walks through voiding the claim and filing it again against the right plan.

When it's the enrollment, not the claim​

If every claim to one payer bounces, the problem is usually upstream — check the payer's enrollment status before debugging individual claims.