Up-front rejections

When you submit a claim with missing or invalid data in required fields, our system rejects it before it enters claims adjudication. This is called a front-end or up-front rejection. No Explanation of Payment (EOP) is generated for these claims.

All claims submitted to Priority Health electronically or by paper must first pass specific edits prior to acceptance. 

  • Electronic claims must pass required X12 HIPAA standard edits.
  • Paper claims must first pass specific edits prior to acceptance.

Notification of front-end rejections

Find your front-end rejections and the reasons for them in our Claims tool. Click on the Up-Front Rejected Claims tab to start your search.

We notify providers by a front-end rejection letter or, if the claim was submitted electronically, a service receipt with the details of the rejection. See an example of a service receipt.

Front-end rejections are not denials

After you review the service receipt, you can make the necessary corrections and resubmit the claim. A "corrected claim" is not required.

Choose how to receive service receipts

Up-front rejected claims and reasons are now available on prism, our provider portal.

  1. Log in to your prism account
  2. Click on the Claims tab and then on Medical Claims
  3. There you can adjust the parameters of your Claims search, including clicking the Rejected Claims toggle
  4. Click the Claim ID on any claim for more details

We can send you claim service receipts through electronic data exchange (EDI), by email, fax or US mail as selected by your office.

To request service receipts through EDI, see EDI setup information.

To get service receipts by fax or email, use the Claim receipt/up-front edit notification form.

If we don't have either your fax number or email address, we will send by US Mail.

Common causes of front-end rejections

Common rejection causes include:

  • Unreadable information - ink is faded, too light, or too bold (bleeding into other characters or beyond the box); the font is too small or hand-written information is not legible
  • Member date of birth missing or incorrect
  • Member name or Identification number missing
  • Provider name, Taxpayer Identification Number (TIN), or National Practitioner Identification (NPI) number missing
  • Attending provider information missing from Loop 2310A on Institutional claims when CLM05-1 (Bill Type) is 11, 12, 21, 22, or 72 or missing from box 48 on the paper UB claim form
  • Date of service not prior to the received date of the claim (future date of service)
  • Date of service or date span missing from required fields, such as "Statement From" or "Service From" dates
  • Type of bill is invalid
  • Diagnosis code missing, invalid, or incomplete
  • Service line detail missing
  • Date of service prior to member's effective date
  • Admission type missing (inpatient facility claims – UB-04, field 14)
  • Patient status missing (inpatient facility claims – UB-04, field 17)
  • Occurrence code/date missing or invalid
  • Revenue code missing or invalid
  • CPT/procedure code missing or invalid
  • CPT/HCPCS/modifier combination invalid
  • Incorrect form type used
  • Taxonomy code and qualifier missing in box 24 I, 24 J or box 33b on the CMS-1500 form