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Rejection vs. Denial

For All Medicare Submitters

To ensure callers are reaching the department that can best assist with their issue, EDISS would like to provide some clarification on the terms "rejection" and "denial."

A "REJECTION" means the claim file stopped processing before it reached Medicare. This results in an error on one of the three acknowledgement reports generated by our front-end system, the TRN, 999, and 277CA reports. In this case, a remittance advice will NOT be generated. EDI would provide assistance with rejection related questions.

A "DENIAL" means the claim processed through EDI, was received by Medicare for processing, but was either not paid or not paid in full by Medicare. This information would be communicated to the provider on a remittance advice. The Provider Contact Center would provide assistance with denial related questions.

Message Sent:
June 2, 2020