The Hidden Burden of Unprocessable Claims

The Top 3 Reasons Claims Aren’t Processable (and How to Prevent Them)

Unprocessable claims aren’t just a momentary inconvenience – they’re an operational roadblock. When claims can’t move forward, payers and TPAs face a ripple effect of inefficiency, added costs, and frustrated stakeholders. But unprocessable claims don’t have to be an inevitable part of the process. By understanding the most common reasons claims get stuck, you can proactively address them to save time, reduce frustration, and streamline your operations. Let’s break down the top 4 reasons claims aren’t processable and how to prevent them.

1. Missing or Incomplete Information

One of the most common reasons claims are deemed unprocessable is missing or incomplete information. This can include absent documentation, incorrect provider details, or incomplete member data. A single missing piece can halt the entire process.

Prevention Tip:
Implement validation tools that flag incomplete submissions at the point of entry. Automated checks for missing fields or mismatched data can reduce manual follow-up and ensure claims move forward seamlessly.

2. Invalid or Outdated Codes

Medical codes that are invalid, outdated, or improperly applied can render a claim unprocessable. With coding systems evolving regularly, staying up to date is essential — but errors can still creep in, especially during transitions to new code versions.

Prevention Tip:
Invest in ongoing training for claims staff and implement coding software that automatically updates to reflect the latest guidelines. Regular audits can also catch and correct coding errors before claims are submitted.

3. Missing Prior Authorizations or Documentation

Certain claims require additional documentation, like prior authorizations or supporting clinical records. When these aren’t included, the claim becomes unprocessable.

Prevention Tip:
Establish clear workflows to ensure prior authorizations are obtained and attached before claims are submitted. Integrate document tracking systems to provide visibility into required attachments, reducing oversights.

The Hidden Burden

Unprocessable claims might seem like small issues in isolation, but their cumulative impact can’t be ignored. Every delayed claim means more administrative work, higher processing costs, and potential frustration for providers and members. Preventing unprocessable claims doesn’t just streamline your operations — it creates a better experience for everyone involved. By addressing these challenges at the source, payers and TPAs can free up resources, improve accuracy, and focus on what matters most: delivering value to stakeholders.

Let’s Fix it Together

At Clarity Performance Solutions, we specialize in helping payers and TPAs eliminate the burden of unprocessable claims. From advanced validation tools to expert consulting, we provide the solutions you need to tackle unprocessable claims at their root. Contact us to reduce inefficiencies to simplify your claims process.