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Resolving Common Claims Rejections

Date: 05/13/25

Meridian Claims Operations provides guidance on common claims rejection reasons to assist providers in quickly resolving rejected claims. A rejected claim is a claim that has missing or insufficient information that will prevent the claim from entering the claim system.

REJECTED CLAIMS GUIDELINES
If a claim is rejected and you are correcting a field and re-submitting the changed claim, please submit the claim as a first-time claim. Rejections are not proof of timely submissions. Rejected claims must be resolved and resubmitted within the timely filing guidelines.

COMMON REJECTIONS

02 REJECTION: Invalid MBR
ISSUE: A member is not valid for the date of service (DOS) being billed.
RESOLUTION

  • Step 1: Review member RIN for the date range (month of the claim) on the State Provider MEDI Healthcare Portal
  • Step 2: If the state file shows that the member is enrolled with Meridian or YouthCare please contact Provider Services for assistance with an updated member record. Provider Services will request that eligibility is updated and give you a case number
  • Step 3: Submit first time claim once member’s eligibility has been updated, within 180 days of the DOS
  • Step 4: If the state file does not show a member enrolled in the plan billed, bill the correct carrier and include the DOS

09 REJECTION: Member Invalid on Date of Service
ISSUE: Member is not showing effective for the DOS billed. The member may have coverage through another carrier, or an update was not transmitted to the plan from the state.
RESOLUTION

  • Step 1: Review member RIN on the state Provider Healthcare Portal for the date range (month of the claim)
  • Step 2: If the state file shows that the member is enrolled with Meridian or YouthCare, please contact Provider Services for assistance with an updated member record. Provider Services will request to have eligibility updated and provide a case number
  • Step 3: Submit first time claim once member’s eligibility has been updated, within 180 days of date of service
  • Step 4: If the state file does not show that member is enrolled to bill Meridian or YouthCare, bill the correct carrier

01 REJECTION: Invalid Member Date of Birth (DOB)
ISSUE: Member’s date of birth does not match resolution
RESOLUTION

  • Step 1: Verify the billed DOB to ensure it matches the DOB in the Illinois MEDI system
  • Step 2: If incorrect on the portal, the member must notify HFS to have the date corrected
  • Step 3: If DOB was entered incorrectly on the claim, correct DOB and submit the claim as a first-time claim
  • Step 4: Verify the DOB loaded with the plan billed matches the Provider Healthcare Portal
  • Step 5: If the two systems do not match, contact Meridian or YouthCare Provider Services to have the member information updated with the health plan
  • Step 6: After updating, submit the claim as a first-time claim

M6 – Provider Not Valid/Found on State File
ISSUE: Provider billed using a Group NPI and/or rendering NPI that is not registered with the state, therefore the group NPI and/or rendering NPI is not listed on the state provider file.

Resolution for Non-Waiver Providers

  • Step 1: Review NPI from claim image against the state provider file to verify that group NPI and rendering NPI are listed and effective for service dates
  • Step 2: If NPI is not listed on the state provider file, the provider must enroll in the Illinois Medicaid Provider Advanced Cloud Technology (IMPACT) system
  • Step 3: If NPI is listed on state provider file, contact Provider Relations for help with loading the NPI to the Meridian or YouthCare provider file

Resolution for Waiver Providers

  • Step 1: Compare Medicaid number billed in Box 33b from claim image against the state provider file to verify that the Medicaid number is listed and effective for service dates as a waiver provider
  • Step 2: If Medicaid number is not listed on the state provider file, the provider must enroll in the IMPACT system
  • Step 3: If The Medicaid number is listed on state provider file, contact Provider Relations for help to get the NPI loaded to the Meridian or YouthCare provider file

Learn more on the: Illinois Association of Medicaid Health Plans (IAMHP) website.

96 – Ordering/Prescribing/Referring
ISSUE: Ordering, prescribing, or referring provider type missing or incorrect

  • Ensure the code type is one the following: 010, 011, 012, 013, 016, 089 and is active compared to the IMPACT File

NOTE

  • For professional claims – CMS 1500: Provider TINs are required on field 25 on a professional claim, and the NPI should be inserted in the rendering provider field (field 24J) and the billing field (field 33).
  • For Facility/Institutional Claims – UB-04: Provider TINs are inserted in field 5 and the facility NPI should go in field 56. Individual provider NPIs are required situationally in fields 76 - 79 (will vary per service performed)

91 — Invalid or Missing Taxonomy Code
ISSUE: Provider submitted incorrect, invalid, or missing taxonomy code
Resolution for Non waiver Provider

  • Step 1: Review claim image to verify that the taxonomy code was billed in Box 24 and Box 33
  • Step 2: Use taxonomy code from claim image to confirm that the code is registered in the IMPACT system
  • Step 3: Correct the missing or invalid taxonomy and resubmit claim as a first-time claim

Resolution for Waiver Provider

  • Step 1: Review claim image to verify that the claim was billed with a Medicaid number in Box 33b as shown below. Please note, if submitting claims via the Meridian Secure Provider Portal, do not type in the G2 when entering the Medicaid number, the portal will automatically add it
    claim example
  • Step 2: If the claim was billed with an NPI, please correct and bill it as a first time claim with the IMPACT registered Medicaid number
  • Step 3: If the claim was submitted correctly with the Medicaid number and continues to reject 91, reach out to Provider Relations for assistance

UB04 claims — Rejects Associated with Attending Physician

UB04 claims are required to be billed with a valid NPI for the attending physician in field 76. If the NPI is missing or invalid the following rejects may occur

  • 28 — Attending Provider NPI Missing or Invalid: no attending provider NPI is received in field 76
  • 03 — Attending NPI Not Enrolled with State: claim has an NPI in field 76, but the NPI is not IMPACT enrolled on the DOS
  • 45 — Invalid or Missing Provider Type:
    • If claim has an NPI that is on the file and active on the DOS, we check to ensure the NPI is enrolled with provider type 010, 011, 012, 013, 016 or 089
    • If the NPI is not one of these provider types on the state file, the NPI is invalid, and is assigned the following rejection:
    • High Dollar and Claims with more than 97 lines
    • Meridian systems cannot ingest claims with a billed amount of $10,000,000 or more, or that are longer than 97 lines. If claims fall under those parameters, they will initially reject:
    • BW — Claim under review
    • BM — Billed charges under review, no further action needed by the provider

Meridian does have a process to monitor these rejects and manually key the claims into the system and no further action will be required by the provider. Please note that the finalized claims will have a different claim number assigned than the claim number received as a rejection.

Secure Provider Portals and Contact Information

For Meridian Provider Services call 866-606-3700, Monday through Friday, from 8 a.m. to 5 p.m. or, for YouthCare Provider Services call 844-289-2264, Monday through Friday, from 8 a.m. to 6 p.m.