New resource: Understanding why a claim is denied
It’s important to us that you understand the way your claims are handled. That’s why we created a new resource to help you understand exactly why a claim may have been denied and be able to take any appropriate next steps.
Understanding claim denial explanation codes
When a clinical edit applies to a claim, our system adds an explanation code with a brief description of the denial reason to the claim details here in prism. Because these explanation codes are often tied to multiple clinical edits, the descriptions seen in the claim details are broad.
For many clinical edits, you’ll see a “See Edits” button in prism, in addition to the explanation code, that provides additional rationale / possible reasons why the edit was used on the claim. However, for some clinical edits, prism doesn’t offer this level of detail.
This new claim denial explanation codes PDF compiles additional information / rationale for the most common clinical edits that isn’t available in prism.