Top 10 Causes of Returned Rezepts and the Reclaim Procedure Fully Explained

"Our rezept was returned"—this is an unavoidable occurrence on the medical clerical frontline. A returned claim can recover revenue if reclaimed, but handling it takes effort and delays payment. This article organizes the typical causes of returned rezepts in a top-10 format and explains, from a practical standpoint, the procedure for reclaiming returned rezepts.

What is a returned claim (henrei)?

A returned claim (henrei) refers to the review and payment organizations (the Social Insurance Medical Fee Payment Fund and the National Health Insurance federations) sending a submitted rezept back to the medical institution when they judge that its content contains doubts or deficiencies. Unlike a point reduction (assessment), a return is a matter of "the claim being put on hold once, then reclaimed after correction and confirmation." For the specific definition of a return and the workflow, please refer to the official materials of the SSK and the Ministry of Health, Labour and Welfare (MHLW).

Top 10 causes of returned rezepts

Here are the return reasons frequently seen in practice, organized from the most representative. Because reason codes and handling differ case by case, always confirm the entries in the increase/decrease notice and the return breakdown when actually responding.

1. Errors in insurance eligibility: Mismatched symbols/numbers or insurer numbers; visits after loss of eligibility
2. Deficiencies in the symbol/number, name, etc.: Input mistakes in insured-person information
3. Missing or inconsistent diagnoses: No diagnosis corresponding to a procedure or medication, or a contradiction
4. Insufficient symptom notes: Inadequate reason statements required for high-cost or specific care
5. Unmet billing requirements: Requirements for additions or management fees not met, or no supporting note
6. Off-label medication or dosage doubts: No indicated diagnosis, or a dosage judged excessive
7. Duplicate claims: Double-billing of the same care, or overlap with another institution
8. Errors in public-expense / combined-insurance entries: Errors in the public payer number or the combined-use category
9. Errors in cross-month claims / handling of returned portions: Mistakes in continuous-care entries or in processing return reclaims
10. Inconsistent entries: Mismatches in the calculation of days, counts, or points, or in codes

Procedure for reclaiming a returned rezept

A returned rezept can be reviewed again by correcting it and reclaiming it. Medical institutions that perform online billing operate, in principle, by reclaiming returns online (see the SSK / federation guidance for the specific operation and timing). The general flow is as follows.

1. Download the return file (return breakdown): Obtain the return data from the online billing system. Note that the downloadable period has a deadline.
2. Confirm the return reason: Identify why it was returned using the breakdown and notice.
3. Import into the receipt computer and correct: Import the return file into the receipt computer (electronic chart) and add diagnoses, symptom notes, or corrections.
4. Create and send the reclaim file: Send the corrected rezept online as a reclaim portion, together with the current month's claims.
5. Confirm the result: Confirm in the following month's notices that the reclaim portion was processed correctly.

There are also cases outside the scope of online handling, such as rezepts returned on paper. Confirm the exact procedure appropriate to your institution's billing method in the latest guidance from the review and payment organization.

From "fixing after it happens" to "not causing it"

Although return handling can recover revenue through reclaiming, it incurs the extra work of confirmation, correction, and resending, and delays the payment cycle. To fundamentally reduce returns, it is most effective to eliminate deficiencies at the pre-submission stage.

• Inspect the correspondence between diagnoses and procedures/medications before submission
• Confirm the billing requirements for additions and management fees and whether the necessary entries are present
• Mechanically check insurance eligibility and combined public-expense entries

Pottech's integrated receipt-computer "AI Karte" uses AI rezept checking to detect, from the care-input stage, points prone to leading to returns and missed billing. Because you can notice a missing diagnosis or an unmet billing requirement on the spot, you can move from an operation of "fixing after a return occurs" toward one of "not causing returns in the first place."

In closing

Most returned rezepts come down to causes preventable by pre-submission checks—such as insurance eligibility, diagnoses, billing requirements, and entry deficiencies. When a return occurs, it is important to confirm the reason using the return file and reclaim it via the correct procedure. On top of that, building pre-submission inspection into your system and reducing returns themselves leads to a lighter burden for clerical staff and stable revenue.

Through the provision of AI Karte, Pottech serves as the optimal business partner for clinics—supporting not only better working conditions for physicians, nurses, and medical clerical staff, but also helping clinics achieve to the fullest what they want to accomplish.

For details, please do not hesitate to contact us.

References / Sources

• Ministry of Health, Labour and Welfare, "Flow of Rezept Return Operations" https://www.mhlw.go.jp/bunya/shakaihosho/iryouseido01/pdf/recept04b.pdf
• Social Insurance Medical Fee Payment Fund, "Guidance on Online Return Reclaims" https://www.ssk.or.jp/seikyushiharai/iryokikan/iryokikan_h281214/index.html
• Social Insurance Medical Fee Payment Fund, "Flow of Medical Fee Review and Payment Operations" https://www.ssk.or.jp/shinryohoshu/gyomuflow/index.html
• Ministry of Health, Labour and Welfare, "Guidance on the Digitalization of Return Reclaims" https://www.mhlw.go.jp/content/12400000/001281172.pdf