How it works
A denial is different from a rejection. A rejection happens before processing — the claim is returned for missing or invalid data and was never adjudicated. A denial happens after the payer has processed the claim. Denials are sometimes called “soft” when they can be fixed with a corrected claim or more information, and “hard” when they need a formal appeal or cannot be recovered.
Why it matters
Each denial costs time to work and has a deadline for correction or appeal. More importantly, repeated denials point to a problem earlier in the cycle — eligibility, authorization, coding or documentation — that will keep producing denials until it is fixed.
Example
A claim is denied with CO 197 because no authorization was on file. The practice can request a retroactive authorization if the payer allows it, but the lasting fix is checking authorization requirements before scheduling. See our claim denial codes guide.