When a third-party payer refuses payment to a provider, what is this called?

A third-party payer refusing payment to a provider is referred to as a denied claim. This designation indicates that, for some reason, the payer has determined that it will not reimburse the provider for the services rendered. Denials can occur for various reasons, such as lack of coverage for the service, insufficient information provided, or failure to meet specific guidelines set forth by the payer.

Understanding denied claims is essential in the reimbursement process, as they often require the provider to take further action—such as appealing the denial or providing additional documentation—to resolve the issue and obtain payment. In contrast, a clean claim is a claim without errors that can be processed without delay, and a rejected claim typically refers to a claim that has not been processed due to technical issues or inaccuracies that prevent it from being billed correctly. An unprocessed claim isn’t specifically defined within standard terminology related to claims but generally means one that is still under review or waiting for processing.