Rejection Scenarios

Rejection Scenarios

In certain cases, the claims you submit through Medicare may not be successful. However, the system is designed to flag these claims with error codes to give you as much information as possible on why the claim was rejected, as well as clues on how to fix it. 

This article will detail common scenarios that will display in the Claiming dashboard (Accounts > Claiming).





Claims that are rejected will display the error message in one of two ways:

1. Hovering on the (i) icon.





2. Opening a claim located In Progress, by clicking View Service and viewing the Description.

Below is a list of common rejection scenarios, along with a brief explanation and general action to take.

Benefit has been previously paid for this service - Medicare is viewing this service as a duplicate. Please follow the Managing Rejections steps to re-submit.

The card number and/or patient details submitted did not match Medicare checks. Please verify the details and resubmit with additional information if available - There is a verification issue between patient details and Medicare details. Please check the details in the record.

Bulk bill additional item claimed incorrectly - The items that are claimed together are not following eligibility rules. Please review the rules listed for the item on the MBS website.

Current Medicare card has expired. Patients must contact Medicare as claims using this Medicare card may be rejected - Current Medicare details for the patient are not up to date. The patient card details will need to be updated.

Invalid value for data item. The data element does not comply with the values permitted or has failed a check digit check - There are discrepancies with the data being sent to Medicare for that claim, which may be due to patient details (e.g. address), the provider (e.g. provider number) and/or the item number(s) submitted. Please check all details and ensure no miscellaneous characters are used.

Invalid format for data item - Some required information is missing or has been entered incorrectly. Please check all details being submitted. (This typically pertains to a mismatched gender)

Desecure failure - Your transmission of information to Medicare has been disrupted temporarily. Please wait a few moments before submitting again.

For a detailed strategy on how to manage these rejections, please refer to the support article Managing Rejections.

For a more comprehensive list of Medicare rejection scenarios, please see the following link: Education guide - Medicare reason codes and reducing claim rejections.

For a more comprehensive list of DVA rejection scenarios, please see the following link: DVA reason codes.