Let's take a look at the Claim related Metrics.
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Rejection Ratio: Rejection Ratio measures the percentage of total rejected insurance claims by submitted claims. It is calculated as:
Rejection Ratio = Rejected Claims (Count)/ Submitted Claims (Count) x 100
Rejected claims here are claims that were changed to rejected status in the selected date range, whereas Submitted claims are claims that were changed to submitted status in the selected date range.-
A high rejection ratio indicates issues with claim accuracy and submission processes, leading to delays in payment and increased administrative workload. A lower rejection ratio indicates a more accurate claim submission process and fewer delays in reimbursement. Common causes of rejections include:
Missing or incorrect patient or insurance details
Invalid procedure or diagnosis codes
Formatting errors or payer-specific submission requirements
Reducing the rejection ratio improves billing efficiency, accelerates revenue collection, and reduces staff time spent on claim corrections. Practices should aim for a low rejection ratio by implementing claim validation checks and proactive error resolution before submission.
Claims Pending Submission (Created Date): This metric represents the gross insurance estimate for all claims that were created during the specified date range but are still pending submission to payers. These claims are still in draft or holding status and have not been sent electronically or printed for mailing. This value helps identify potential revenue sitting in the queue and signals delays or gaps in the claim submission process. This includes claims that have never been submitted even once.
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Submitted Claims (Count): This metric counts all claims that were submitted to insurance payers during the specified date range. It includes:
Original claims
Resubmissions
Claims that were submitted during the date range but have since been deleted
The focus is on tracking all claim submission activity that occurred within the timeframe, regardless of the current status of the claim. This helps practices monitor billing volume and rework trends, even if certain claims are no longer active in the system.
| Note: These are not based on claims that are currently submitted rather claims that were submitted in the date range selected. |
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Rejected Claims (Count): Rejected Claims (Count) represents the total number of insurance claims that were rejected by either the clearinghouse or the payer before entering the adjudication process. Unlike denied claims, rejected claims contain errors that prevent them from being processed and must be corrected and resubmitted for payment consideration.
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Common reasons for claim rejections include:
Incorrect or missing patient or insurance details
Invalid or mismatched procedure and diagnosis codes
Formatting or submission errors
Payer-specific billing requirements not met
A high rejected claims count indicates potential inefficiencies in claim submission workflows and may contribute to delayed revenue collection. Monitoring and reducing claim rejections can improve billing accuracy, streamline administrative processes, and accelerate cash flow.
This metric considers claims currently in Rejected, Rejected (CH) statuses and is based on Treatment Location, Treatment Provider and DOS of the claim.
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Clean Claim Rate: Clean Claim Rate measures the percentage of electronic insurance claims that are accepted by payers on the first submission without errors, rejections, or denials. A "clean" claim in this context means that the claim is correctly completed, formatted, and includes all necessary information, leading to immediate payer acceptance upon the first attempt.
A higher rate for first submission clean claims indicates an efficient and accurate initial claim submission process, which is crucial for improving cash flow and reducing administrative burden. Practices that achieve a high first submission rate benefit from quicker reimbursements and fewer issues related to billing errors.
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Key factors influencing first submission clean claims include:
Accurate patient, insurance, and procedure information
Proper coding and formatting per payer guidelines
Timely submission and adherence to payer deadlines
Tracking this metric helps identify areas where claims may be prone to errors or rejections on the first submission, allowing practices to focus on improving data accuracy and claim submission procedures to reduce rework and delays.
This metric considers all electronic claims that had an intial submission date between the selected date range.
Clean Claim Rate = ((All Electronic Claims Submitted excluding Open Claims) - Electronic Claims in ['Rejected (CH)' status + ‘Rejected’ status + Outstanding payment for 30 days from submitted date + Any claims that are resubmitted]) / (All Electronic Claims Submitted excluding Open Claims)
All Electronic Claims Submitted = Claims with statuses not in [Saved, Saved with Error, On Hold, On Hold with Error, Document Pending, Ready to Send].
Open Claims = Consider all statuses listed under ‘Pending Payment’ tab except Resubmitted (CH), Resubmitted (Payor), Partially Paid, Resubmitted (Payor) - E that have been open for <= 30 days. Basically in this section we include open claims that a user has not worked on; this includes claim statuses such as ‘Denied' and ‘Error (CH)’ since they still have not been actioned by a user.
Outstanding payment for 30 days from the submitted date = Consider all statuses listed under the ‘Pending Payment’ tab inside the Claims module and have been in any of those statuses for > 30 days from the claim submission date.
Any claims that are resubmitted = Claims that were ever in ‘Resubmitted (CH)’ or ‘Resubmitted (Payor)’ status.
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Claim Pending Submission (All Time): Claim Pending Submission (All Time) represents the total value of insurance production and insurance adjustment from claims that have been generated in the system but have not yet been submitted to insurance payers.
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Claims in statuses Saved, Saved with Errors, On Hold, Document Pending are considered for this metric. These claims may be pending due to various reasons, such as:
Missing or incorrect patient/insurance information
Pending provider review or approval
Claim validation errors requiring correction
Delays in batch processing or manual submission
Since unsubmitted claims directly impact cash flow and revenue cycle efficiency, practices should regularly monitor this metric to ensure timely claim submission. A high balance in this category may indicate workflow bottlenecks, staff training needs, or system issues that require attention. Reducing claim submission delays helps accelerate reimbursements and minimizes the risk of timely filing denials.
This metric is based on an all time value and calculated based on Treatment Location and Treatment Provider.
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Claims Rejected (All Time): Claims Rejected (All Time) represents the total value of insurance production and insurance adjustment from claims that have been rejected by either the clearinghouse or the payer before processing. Unlike denied claims, rejected claims never reach adjudication and must be corrected and resubmitted to be considered for payment.
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Common reasons for claim rejections include:
Missing or incorrect patient or insurance details
Invalid or outdated procedure or diagnosis codes
Formatting errors in claim submission
Payer-specific requirements not met
Rejected claims impact the revenue cycle by delaying payments and increasing administrative workload. A high rejection rate suggests potential issues with claim accuracy and submission processes. Practices should regularly monitor this metric and implement claim scrubbing and validation checks to minimize rejections and improve cash flow.
This metric only considers claims currently in Rejected, Rejected (CH) statuses and calculated based on Treatment Location and Treatment Provider.
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Practices can use this simple guide to learn about claim related metrics.