Rejected because a referral letter was missing.
A mid-sized clinic submits a claim. Six weeks later it comes back: a missing referral, a diagnosis code that did not pair with the procedure code, a signature on the wrong form.
None of this is a dispute about whether the treatment happened or whether it was covered.
The clinic corrects and resubmits, and another four weeks pass. A clinic with two hundred beds can hold several billion rupiah in claims that are recoverable and uncollected.
One rejected claim, item by item
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01
Patient identity and policy numberPresent
Copied from the card at reception. This part almost never fails.
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02
Diagnosis codePresent
Entered by the doctor after the consultation, from the clinic's own code list.
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03
Procedure codeConflict
Valid on its own. Does not pair with the diagnosis code under this insurer's current rules, which changed in March.
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04
Referral letterMissing
Required for this procedure under this policy. The patient did not have one and nobody asked, because nothing at the desk said to.
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05
Doctor's signatureWrong form
Signed on the clinic's internal form rather than the insurer's, which is a different page in the same folder.
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06
Treatment and costPresent
Never in dispute. The treatment happened, it was covered, and the amount is correct.
Four of six items are fine. Two of the remaining three could have been fixed in the ninety seconds the patient was still standing at the desk.
If you submit claims, or assess them.
The useful thing is your actual rejection reasons and how long a round trip takes.