Cover not checked before the service
The most expensive of all, because the treatment has already happened. Eligibility has to be part of arrival, not a task for later.
Blog
Why NPHIES claims get rejected, and what to do about it
Almost every clinic treats rejections as individual misfortunes to be appealed. Sorted by reason instead, they resolve into a very short list — and most of that list is fixed before the claim is submitted, not after.
Sort before you appeal
The first useful move costs nothing: group last quarter’s rejections by reason code and count them. Almost every clinic finds that two or three reasons account for most of the volume, and that those reasons are procedural rather than clinical.
Eligibility not verified, service not covered under the plan, missing pre-authorisation, documentation not attached, coding that does not match the note. None of those are arguments about medicine. All of them happen before the claim exists.
The four that recur
Authorisation missing or expired
Approvals have a life. One granted six weeks ago for a session that slipped is a rejection waiting to be submitted.
Documentation not attached
The note exists, it is just not on the claim. This is the easiest to automate away and the most commonly left manual.
Coding that does not match the record
Usually a coding step separated from the clinical one, so two people describe the same visit differently.
Fixing the pattern rather than the claim
Appealing a rejection recovers one claim. Changing what happens before submission recovers the next hundred, and the two are not the same work.
The practical change is that each recurring reason becomes a check that blocks submission: no eligibility response on file, no claim. Authorisation expired, flagged before the session rather than after it.
Then measure what each company actually pays, per service, over time. Not what they say they pay — what arrived. That number ends more contract conversations than any appeal.
Questions
How long do we have to appeal?
It depends on the payer and the contract, and the window is usually shorter than clinics assume. The practical answer is to track the deadline per claim rather than per batch.
Should we appeal everything?
No. Appeal what is worth the administrative cost and fix the rest at source. A clinic appealing every rejection is spending more on recovery than prevention would cost.
What is the single highest-return fix?
Eligibility before the service. It prevents the rejections that cannot be recovered, because the cost has already been incurred.
How do we know which reasons matter?
Group by reason code and sort by value, not by count. Ten small rejections and one large one are not the same problem.
See it on your own clinic
Thirty minutes on how your clinic actually runs. We will call you within 24 hours.