Community

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

After you create a claim in SimplePractice, our system will update the status for you automatically 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.

 

Within SimplePractice your claim can be assigned any of the following statuses. In this guide, we'll walk through what each status means in detail:

Whenever a claim's status updates to Paid, Denied, Deductible, or Rejected, SimplePractice will send a Claim Status Email to notify you. For group practices, this email notification will only be sent to the Account Owner, the Primary Clinician, and any Biller team members.

To see the current status of any claims you've created, go to Billing > Insurance > Claims:

Insurance.SimplePractice.Claims.png

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

Here's an explanation of the different states a claim can have in SimplePractice: 


Prepared

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

Next steps:

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

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

Downloaded

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

If at any time you edit a claim in this state it will 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.


Scrub

When you click Submit on any claim created in SimplePractice, it will 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, our system will prevent the claim from being submitted and assign the Scrub status to the claim. 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.

This acts as a safeguard to prevent unnecessary claim rejections and allows you can make the corrections before submitting the claim to the payer. You won't be charged for claims that receive a scrub error.

Next step: Click on the claim to review the specific errors that require attention before the claim can be submitted. You can refer to our guide: Scrub errors when trying to file insurance claims for tips on how to resolve these errors.


Submitted

When a claim passes the first round of internal review by our system and is successfully submitted to the payer, it will update to the Submitted status.

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


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 steps:

Payers will vary in the amount of information that 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 do not and will use these two statuses interchangeably. If your claim remains in the Received status, this does not necessarily indicate that there's an issue with the claim. 

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 more than 30 days ago. For more tips on this scenario, see our guide: 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 will soon update the claim status and does not indicate that there's an issue with the claim. In this case, we recommend waiting up to one week to allow the payer enough time to update the claim to its final status.

Next steps:

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 the payers, but not all payers will share this intermediary status with us. This is not a finalized status and it doesn't indicate that there is an issue with the claim.

Next Steps:

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 will be reimbursed based on the client's insurance plan and that the Explanation of Benefits (also known as the EOB, ERA, or payment report) for this claim will be sent. 

Next Steps:

  1. If you are not enrolled for payment reports with the payer, once you receive the payment and EOB be sure to add the payment to SimplePractice.
  2. If you're enrolled in payment reports for this payer, we'll automatically add the payment to SimplePractice, allocate the funds to individual sessions for you, and update the claim status to Paid.

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 does not indicate that there is 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, see our guide: What should I do if my claim is stuck in the Accepted state? 

Tip: Integrated payment reports in SimplePractice is one of our most-loved features. Save time and keep your accounting records up to date. To learn more, see our guide: How to enroll for payment reports.


Rejected

This indicates that the electronic claim filed through SimplePractice was rejected by either the clearinghouse or by the insurance payer.

Next Step: Click on the claim to review the rejection reason at the top of the page. 

Tip: Refer to our guide: Common claim rejections: What they mean and what actions you should take to save yourself time and learn more about resolving claim rejections.

Once you've determined what needs to be corrected, you may update the claim to resubmit. To help you determine the appropriate format required for resubmitting a claim, see our guide: When to submit a corrected claim in SimplePractice and how.


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 is not a reimbursable claim based on your contract with the insurance company.

Next step: If there is no additional information provided by the payer, call the payer to find out the reason for the denial and then resubmit the claim if appropriate.


Deductible

This indicates that the claim was denied payment because the client has not yet met their deductible.

If the claim is denied because the client has not yet met the deductible, the client is now responsible to pay the portion of the session fee that insurance will not cover- the full Contractual Obligation (CO). If you receive payment reports for the payer, (and the sessions' billing type is set to Insurance pays me), SimplePractice will automatically update the amount the client now owes for these sessions.

Note: On the client's billing details page be sure to confirm that the Insurance portion for the denied sessions now reads $0.

You can read more about managing client deductibles here.


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.


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 (or if the payer does not deliver an accurate payment report), you'll see this state when you've manually added insurance payments and all the sessions on the claim have a reimbursement applied to them.
  • If you are enrolled for payment reports, you'll see this state when the electronic payment report is delivered.

Because of the information contained in the payment report, SimplePractice automatically applies the reimbursements to the sessions included in the claim and update your bookkeeping. This is a very useful feature that will save you from having to manually enter all the information from the EOB.

Read more about electronic payment reports here: Payment Reports.

Have more questions? Submit a request