Understanding and preventing healthcare claim rejections
In the complex landscape of healthcare administration, rejected claims can cause unnecessary delays, impact cash flow, and interrupt patient care. Understanding the common causes of claim rejections is the first step toward prevention.
This article explores the most frequent reasons for claim rejections and offers practical, actionable strategies to prevent them. Whether you’re a solo practitioner or part of a large healthcare practice, these insights will help you navigate the claiming process with greater confidence and success.
Keep in mind that provider approval is administered by HICAPS but requires health funds to individually accept. With some funds this is automatic, other can take up to two weeks to approve.
1. Incorrect patient or policy details
Ensure patient details match exactly with what’s on their private health insurance card.
Double-check membership numbers and confirm that the patient’s policy covers the service being claimed.
2. Expired or Ineligible Coverage
Verify patients’ insurance status before processing claims. Some policies have exclusions or annual limits that may have already been reached.
Get a rebate estimate by submitting a health fund quote.
If unsure, encourage patients to check with their insurer before the appointment.
3. Mismatched Provider Details
Ensure the provider number registered with HICAPS matches the practitioner delivering the service.
If a new provider has joined the practice, ensure they are fully registered with HICAPS before processing claims.
If you need to make changes to your payee provider number, learn more How to add/modify a payee provider number for HICAPS terminal
4. Incorrect Item Codes or Service Descriptions
Use the correct item codes as per health fund guidelines. Insurers regularly update item codes, so keeping up to date is essential.
Ensure service descriptions align with the item codes selected. Some codes are specific to treatment types or provider specialties.
Refer to item codes here
5. Claiming Outside Approved Timeframes
Some health funds have strict timeframes for claims (e.g., within six months of service). Encourage patients to process claims promptly.
If a claim is delayed, check with the insurer on whether manual submission is required.
To learn more about reversing a claim or a refund, click here
6. Terminal Errors or Connectivity Issues
Regularly update your HICAPS terminal software to prevent compatibility issues. This can be done by simply putting it back on the base and making sure it’s turned on.
If a claim is unexpectedly declined, confirm internet or EFTPOS connectivity before retrying.
View all HICAPS Terminal health fund and EFTPOS error codes here