Checking a Claim Status: The different phases of an insurance claim

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SimplePractice automatically updates the claim status for you. We use the codes insurance payers provide in order to update the status for you. Within SimplePractice, your claim can have 13 unique states:

Prepared 
Downloaded 
Scrub 
Submitted 
Received 
Pending 
More Info Required 
Accepted 
Rejected 
Denied
Deductible 
Paid Pending 
Paid

You can see the status of every CMS 1500 (HCFA) claim form you create by going to Billing > Insurance > Claims. Click here to learn more: How to check on the status of your claim.

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

 

Prepared

 

This is a claim that has been created but not submitted or downloaded. You haven't done anything with this claim yet.

Next Step:

1) Submit this claim via SimplePractice. Its status will change to Submitted.

2) If you choose to submit the claim outside of SimplePractice, download the claim to print it and file it. When you download a claim, it's status will change to "CMS 1500." 

 

Downloaded

This is a claim you have downloaded and plan to file outside of SimplePractice. This status indicates that this claim exists as a PDF somewhere outside of SimplePractice.

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.

Next Step: 

1) If you are enrolled for payment reports with the payer, SimplePractice will use this info to automatically update the claim by recording and allocating the insurance payment when it is made.(This is a great feature that can save you a lot of time. We strongly recommend enrolling for payment reports even if you don't plan to file claims through SimplePractice.)

2) If you are not enrolled for payment reports with the payer, SimplePractice cannot track the progress of this claim submitted outside of SimplePractice. When you receive payment for this claim, be sure to manually record the insurance payment.  

 

Scrub

This state indicates that you tried to submit the claim but we found errors on it before it was sent to the insurance company. 

You are not charged for claims that are rejected due to a scrubbing error.

Next Step: 

1) Click on the claim to see the specific errors that require attention before the claim can be submitted. 

 

Submitted

 

This is a claim that has been successfully passed the first round of scrubbing in SimplePractice and has been submitted to the payer.

Once a claim is successfully submitted, this will count against the allotted amount of insurance claims you purchased with your online claim filing package.

 

Received

 

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

Processing times vary by insurance company. Some process claims the same day they are submitted. Others like Blue Cross Blue Shield and Medicare/Medicaid can take longer. Most claims are processed in under a week. 

 

Pending

This is an intermediate state. The payer is indicating that they will soon update the claim status. If the payer doesn't update this claim quickly enough, you can call the payer to find out what's causing the delay.

 

More Info Required

This is also an intermediate state. This status is usually assigned to a claim when it's being reviewed by the payer. All claims are reviewed and audited by the payers but the payers don't always share that information with us. 

Next Step:

1) The payer should be updating the status of this claim within 7-10 business days. If the claim is Accepted, there is no action required from you. If they reject the claim, the payer will let you know why so you can make corrections and resubmit.

 

2) If you don't hear back from the payer within the time noted, contact them directly and find out why they're holding payment back. 

Accepted

 

This is a claim that was filed online through SimplePractice and has been accepted into the adjudication process by the insurance company. This indicates that the reimbursement and EOB (ERA, payment report) for this claim will be sent.

Next Step:

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.

(Integrated payment reports is a great feature that will save you a ton of time- no more typing in information from an EOB! Be sure to enroll for payment reports now: How to enroll for payment reports.)

 

Rejected

 

This indicates the online claim filed through SimplePractice was rejected by the insurance company.

Next Step:

1) Click on the claim to see the reasons the claim was rejected. Once you update the claim you can resubmit it the same way you initially submitted it.

Read more about what to do if your claim is rejected here: Rejected claims- What should you do?

 

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. 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. 

 

Paid

 

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 on the payment report, SimplePractice is able to automatically apply 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

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