Turning Claim Rejections into Resolved Revenue
Identifies the reason behind the rejection, analyse the root cause and correct the claim through the approved workflow and resubmit it with clear documentation.
Goes Beyond the Rejection to Identify the Root Cause
We audit every rejected claim, payer and clearinghouse message to determine why processing failed and what needs to be corrected. We then connect each issue to the appropriate resolution workflow, helping practices address rejected claims efficiently while identifying recurring problems that may be affecting claim submission.
Rejection vs. Denial: Where Does the Problem Occur?
Claim Rejection
Typically occurs before payer adjudication, when a claim cannot be processed as submitted due to an error or missing information.
- Incorrect or missing patient information
- Invalid claim or transaction data
- Formatting or submission errors
- Eligibility-related issues
- Missing or incorrect billing details
Claim Denial
Occurs after payer adjudication, when the payer has reviewed the claim and determines it will not be paid as submitted.
- Claim reviewed and adjudicated by payer
- Determination made that claim will not be paid as submitted
- Requires multi-stage clinical review, documentation or appeal
From Rejection Data to Actionable Resolution
A rejected claim tells you something. Shoreline turns that information into the right action.
Decode the Rejection
Clearinghouse and payer rejection messages are reviewed to determine what prevented successful processing. Shoreline helps distinguish the actual issue from symptoms so the appropriate corrective action can be identified.
- EDI 277CA clearinghouse claim status
- ANSI rejection codes (CARC & RARC)
- Payer front-end portal error messages
- Root-cause vs. symptom isolation
Route the Right Correction
Demographic errors should go to demographic correction. Coding-related issues should reach the coding workflow. Authorization-related issues should be routed appropriately.
- Demographic mismatches to patient access
- CPT/ICD-10 discrepancies to AAPC coders
- Prior-auth lapses to authorization team
- Payer rule conflicts to clearinghouse team
Prioritize Filing Risk
Rejected claims approaching applicable filing limits can be surfaced for priority handling according to client-approved rules.
- Filing window limits monitored by payer
- Aging rejection queue triage (< 48 hrs)
- High-dollar claim recovery sequencing
- Automated urgent escalation alerts
Find Repeat Causes
Shoreline can categorize recurring rejection patterns by payer, provider, location, error type, or workflow source to identify trends and expose upstream problems.
- Payer-specific rejection trend analytics
- Provider & clinic location error rates
- Front-desk registration accuracy logs
- Clearinghouse validation rule shifts
Close the Learning Loop
Rejection intelligence can be fed back into the process that caused the error. When recurring issues are identified and addressed upstream, claim correction becomes part of a continuous improvement cycle—not just a reactive billing task.
- Pre-submission scrubbing rule updates
- Front-desk registration feedback loops
- Payer policy shift alert distribution
- Monthly audit scorecards & revenue reviews
What Does our Claim Audit Looks For?
We examine the rejected claims to identify the specific factors preventing successful processing and the patterns behind them.
Don't Let Rejected Claims Become Lost Revenue
Shoreline helps medical practices bring structure and intelligence to claim audits and rejection resolution so rejected claims become opportunities to correct the process, not recurring revenue problems.