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Checking a claim status: The different phases of an insurance claim


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Checking a claim status: The different phases of an insurance claim

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Checking a claim status: The different phases of an insurance claim

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  • Updated

After you create a claim in SimplePractice, it's status will automatically update based on the claim's history in your account, status updates received from the payer, the payment status of the appointments billed on the claim, or from electronic Payment Reports (ERAs) if you're enrolled with that payer through SimplePractice.

Important: If you're not enrolled to receive Payment Reports from a payer, a successfully submitted claim will only update as far as Accepted, and you'll receive an Explanation of Benefits (EOB) outside of SimplePractice indicating the claim's final status. To automate your bookkeeping, we recommend submitting Payment Report enrollments for payers you work with. 

In this guide, we'll walk through what each claim status means and any action steps that are needed: 

To see the current status of any claims you've created, navigate to Insurance > Claims.

claims.simplepractice.claims.png

This page will show you the date that the claim was created and the current status of the claim. Clicking View will take you directly to that specific claim. 

Prepared

After you create and save a claim in SimplePractice, it will show the Prepared status. This indicates that the claim was successfully created and stored in your account, but it hasn't yet been submitted or downloaded.

Next step:

If a claim is in the Prepared state, the payer hasn't received the claim for processing. In order to submit the claim to the payer, you can either:

  • Submit it electronically via SimplePractice
  • Download it to your computer where you can print and file the claim by mail, or through a different clearinghouse. 

Downloaded

This status appears when a claim is downloaded to your computer. It indicates to the system that you plan to file it outside of SimplePractice either by mail or through a different clearinghouse. 

If you edit a claim in this state, it’ll return to the Prepared state. This indicates that the information on the claim has been updated and this new version of the claim hasn't yet been submitted or downloaded.

Note: Box 31 populates with the date a claim is created. If a claim is downloaded, the date it was downloaded will populate Box 31 of the PDF version of the claim. 

Scrub

When you click Submit on any claim created in SimplePractice, it'll first go through our automated internal review system, which scans each claim for any evident errors that would ultimately trigger a claim rejection from the payer.

If an error is detected, we'll prevent the claim from being submitted and assign it the Scrub status. When viewing the claim, you'll see a message at the top of the page outlining exactly what needs to be corrected and the field(s) causing the error will be outlined in red.

Note: A scrub takes place before a claim makes its way to the payer. Because the claim isn't processed, you won't be charged for claims that receive a scrub error. 

This acts as a safeguard to prevent unnecessary claim rejections and allows you to make the corrections before submitting the claim to the payer. 

Next step: 

Click on the claim to review the specific errors that require attention before the claim can be submitted. For steps on how to resolve common scrub errors, see Scrub errors when trying to file insurance claims. 

Submitted

When a claim passes the first round of internal review by our system and is successfully submitted to the payer, it'll update to the Submitted status. A claim generally won't take more than a day or two to update past the Submitted status. 

After a claim is successfully submitted, the claim filing fee will apply.

Next step:

Allow the claim a couple of days to move past the Submitted status. If the claim remains in the Submitted status for a prolonged period of time, you can submit a help request and our team can investigate if there's an issue on the payer's end. 

Received

This status update occurs when the payer acknowledges that they have received the claim for processing.

Important: Processing times can vary by insurance company. On average, most claims are typically processed in 1-2 weeks. Other payers may process claims in as little as one day after being Received, while Blue Cross Blue Shield and Medicare/Medicaid may take longer. 

Next step:

Payers vary in the amount of information they share with our team, and the status updates that you receive may differ depending on which payer you're submitting claims to. After a claim is Received, certain payers will send an additional status update to indicate that the claim was Accepted while others don't and will use these two statuses interchangeably. If your claim remains in the Received status, this doesn't necessarily indicate that there's an issue with the claim. 

If a payer generally sends an Accepted status, but certain claims to the same payer remain in the Received status for a prolonged amount of time, it can indicate that there's an issue with the claim(s). 

We recommend contacting the payer for a status update if you haven't received an EOB or a payment report for a claim that was submitted and has been in the Accepted or Received status for more than 30 days. For more tips on this scenario, see What should I do if my claim is stuck in the "Accepted" state?

Pending

Payers will assign a claim the Pending status as an intermediate state. This indicates that they‘ll update the claim status soon.

Next step:

We recommend waiting up to one week to allow the payer time to update the claim to its final status. If the payer doesn't update the claim after one week, we recommend calling the payer directly to determine what's causing the delay.

More Info Required

Payers will sometimes assign a claim the More Info Required status to indicate that a claim is still being reviewed. All claims are reviewed and audited by payers, but not all payers will share this intermediary status with us. This isn’t a finalized status and it doesn't indicate that there’s an issue with the claim.

Next step:

The payer will typically assign the finalized status of this claim within 7-10 business days. If the claim is Accepted, there will be no further action required from you. If the claim is Rejected, the payer will let you know why so you can make corrections and resubmit.

If a claim remains in the More Info Required status for longer than 10 business days, we recommend contacting the payer directly to determine what's causing the delay.

Accepted

This status is assigned to claims that were filed online through SimplePractice when they have been accepted into the adjudication process by the insurance company. This indicates that the claim has made it past any scrub errors or rejections and will be processed based on the client's insurance plan. 

Next step:

  • If you're not enrolled for Payment Reports with the insurance payer, this will be the last status sent to SimplePractice for the claim. If you receive a payment, you can manually add it to update the claim to Paid. A claim can also be denied after being accepted. If you're not enrolled to receive Payment Reports, the payer will notify you of the denial by sending you an EOB directly. 
  • If you're enrolled to receive Payment Reports for the insurance payer, the status of the claim will automatically update based on the Payment Report sent from the payer. If this is a payment, we'll update the claim status to Paid and allocate the funds to the individual appointments. 

Note: If the claim is in the Accepted status and includes a message saying Entity code required, this is language used by the payer and doesn't indicate that there's an issue with the claim. 

If you're enrolled for Payment Reports and a claim hasn't moved past the Accepted state after the expected processing time, there may be an issue on the payer's end. For more information on what to do next, see What should I do if my claim is stuck in the Accepted state? 

Rejected

This indicates that the claim filed through SimplePractice and processed by our clearinghouse was rejected by the payer or one of the payer's trading partners. This is often due to incorrect or invalid information that doesn't match what's on file with the payer.

Next step:

Open the claim to review the rejection reason at the top of the page. 

Tip: For more information on claim rejections and common causes, see Resolving claim rejections.

Once you've determined what needs to be corrected, delete the rejected claim, make the necessary changes to the client's file or appointment, and create a new claim for that date(s) of service. 

Important: Before deleting a rejected claim, we highly recommend downloading a copy and saving its clearinghouse reference number. Many of our customers choose to store these in the client's file for their records. To learn more about storing client information, see How do I store client documents? 

Denied

This indicates that the payer processed the claim but denied payment. This could be due to the way the claim was coded or because it isn’t a reimbursable claim based on your contract with the insurance company.

Next step: 

If there’s no additional information provided by the payer, reach out to the payer directly to find out the reason for the denial and then resubmit the claim if appropriate.

Denied claims will often need to be resubmitted as corrected claims. See When to submit a corrected claim in SimplePractice and how for instructions on how to do this. 

For additional information on denied claims, see What do I do if my claim is denied?  

Note: You’ll only receive a Denied status in your SimplePractice account if you’re enrolled to receive Payment Reports for that payer. If you’re not enrolled to receive Payment Reports, payers will send an EOB with the denial reason via mail, and the claim will remain in the Accepted status in your account.  

Deductible

This indicates that the claim was denied payment because the client hasn't yet met their deductible.

If the claim is denied because the client has not yet met their deductible, the client is responsible to pay the portion of the session fee that insurance doesn’t cover. If you receive Payment Reports for the payer, SimplePractice will automatically update the amount the client now owes for these sessions.

Next step:

If you receive a Payment Report for a claim that was applied to the client's deductible, SimplePractice won't automatically record the $0 insurance payment. You’ll still need to create a manual insurance payment using the information on the Payment Report. For a detailed walkthrough of this process, see How do I bill clients who haven't met their deductible?

Paid Pending

This status means the payer has authorized payment but has not yet delivered the Payment Report. You'll only see this status if you're enrolled for Payment Reports.

Next step:

Allow the payer more time to send the Payment Report. 

This state indicates that this claim has been processed and a payment has been received.

  • If you're not enrolled for Payment Reports with the payer, you'll see this state when you've manually added the insurance payment and each of the following conditions is met:
    • The Insurance Paid plus the Insurance Write-Off amounts for each appointment equal the Insurance Charged amount for each date of service
    • The Client Responsibility plus the Insurance Charged amounts for each appointment equal the appointments' total Fee
    • Box 28 on the claim form equals the sum of all appointment fees
    • An insurance payment is applied to every appointment on the claim
  • If you're enrolled for Payment Reports, you'll see this status when the electronic Payment Report is delivered.

SimplePractice automatically applies the reimbursements to the sessions included in the claim and updates your bookkeeping. This is a very useful feature that'll save you from having to manually enter the information from the EOB.

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