What are Claim Statuses?
Claim Status helps a user to know what needs to be done with a claim or what has been done with a claim. Claim Statuses should be used to assist a user with the work flow of claims.
NOTE: It is ultimately up to the user to make sure that they are working their aged claims appropriately and not focusing just on claim status alone when working claims.
How do I change a Claim Status?
A claim status is changed from within the Claim Entry screen, in the upper left-hand corner:
What Claim Status options are available?
There are four different types of Claim Status available: System Status, Biller Defined Status, Submitted Status, and EMR Status.
System Status: These are statuses that will typically be assigned to the claim as the claims are processed.
- Done - This status means that the claim is completed. This status should only be used when the claim has a zero balance.
- Ready to Send Primary, Electronic - This status means that the claim is ready to be sent electronically to the primary insurance.
- Ready to Send Secondary, Electronic - This status means that the claim is ready to be sent electronically to the secondary insurance.
- Ready to Send Tertiary, Electronic - This status means that the claim is ready to be sent electronically to the tertiary insurance.
- Ready to Send Primary, Paper - This status means that the claim is ready to be sent on paper to the primary insurance.
- Ready to Send Secondary, Paper - This status means that the claim is ready to be sent on paper to the secondary insurance.
- Ready to Send Tertiary, Paper - This status means that the claim is ready to be sent on paper to the tertiary insurance.
- Ready to Send, Statement - This status means that the claim is ready to be billed to the responsible party using a statement.
- Sent, Statement - This status means that the claim has been billed to the responsible party using a statement. The status of the claim will be automatically updated to this status when a statement has been prepared and processed for the claim..
- Sent, Electronic - This status means that the claim has been sent electronically to an insurance. The status of the claim will be automatically updated to this status when the payer acknowledges receipt of receiving the claim electronically.
- Sent, Paper - This status means that the claim has been sent on paper to an insurance. The status of the claim will be automatically updated to this status when a paper claim has been prepared and processed for the claim.
- Refund - This status means that the claim has a refund (credit) balance.
- Rejected - This status means that the claim has failed Billing validations, has been rejected by the clearinghouse, or has been rejected by the payer.
NOTE: The Ready to Send statuses are the default status when a claim is entered manually by a user, rather than through the EMR Superbill. However, an EMR status may switch to a Ready to Send status based on how the claim is being worked.
Biller Defined Status: These statuses are user statuses, and only a user can change the status of a claim to one of these statuses. These statuses are not system assigned (except in one circumstance). NOTE: Biller Defined Status does not indicate that a new status can be added. It indicates that it is a status that is not automatically assigned by the system.
- Appeal - Use this status to indicate that the claim is being appealed.
- Collection - Use this status to indicate that the claim has been sent to collections.
- Crossover - Use this status to indicate that the claim has been crossed over to the secondary payer by Medicare. (This is the one exception; if you are receiving ERAs the system will update a claim to this status automatically upon batch disbursement if the ERA notified us that the claim was crossed over.)
- In Progress - Use this status to indicate that the claim is in progress.
- Info. requested from office - Use this status to indicate that information has been requested from the provider's office for the claim.
- Hold - Use this status to indicate that the claim is on hold.
- Return Mail - Use this status to indicate that the claim has been returned via mail.
- Pending Collection - Use this status to indicate that the claim is currently pending review before being sent to collections.
Submitted Status: These statuses are to show the progress of the claim filing.
- In process - step 1, Electronic - This status means that the claim has just been prepared.
- In process - step 2, Electronic - This status means that the claim has been prepared and is waiting to be processed from Claim Submission, or that the claim has been prepared and processed and is waiting for acknowledgement by the clearinghouse.
- In process - step 3, Electronic - This status means that the claim has been accepted by the clearinghouse and has been forwarded on to the payer electronically.
- In process - step 1, Paper - This status means that the claim has just been prepared.
- In process - step 2, Paper - This status means that the claim has been prepared and is waiting to be processed from Claim Submission.
- In process - step 1, Statement - This status means that the claim has just been prepared.
- In process - step 2, Statement - This status means that the claim has been prepared and is waiting to be processed from Claim Submission.
NOTE: Claims begin aging when they reach status In process - step 3, Electronic. Some payers do not send back an acknowledgement when claims are received; therefore claims in this status are not
“stuck” but should be worked in a manner equal to claims in a Sent Electronic status.
EMR Status: These are the statuses set when a claim has been created via the electronic superbill in the EMR.
- Open - Electronic Superbill - This status means that the claim has been created via an electronic superbill and that the superbill has not yet been released to be processed.
- Closed - Electronic Superbill - This status means that the claim has been created via an electronic superbill and that the superbill has been released for processing.
