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What should I do if my claim is stuck in the "Received" or "Accepted" state?

What should I do if my claim is stuck in the "Received" or "Accepted" state?

The average claim processing time varies by payer. However, if you haven’t received an update on a claim after 30 days, it’s possible there was a processing issue causing it to be stuck in the Accepted or Received status. In this case, the claim(s) may require following up on. In this guide, we’ll cover: 

Understanding the Accepted/Received status

A claim will go through several status updates in your SimplePractice account. An Accepted or Received status indicates that the claim made it past any initial scrubs or rejections and has entered the payer’s adjudication system where it will be processed accordingly.  

Note: For a full list of claim statuses in SimplePractice, see Checking a claim status: The different phases of an insurance claim

If you’re enrolled to receive Payment Reports (ERAs), the claim will automatically update to Paid, Denied, or Deductible, depending on how the payer processed it. If you’re not enrolled to receive Payment Reports, the Accepted or Received status will be the last status the payer shares with our clearinghouse and you’ll receive an Explanation of Benefits once the payer has finished processing the claim. 

If 30 days have passed and the claim status hasn’t updated automatically via Payment Report, or you haven’t received an Explanation of Benefits, we recommend reaching out to the payer directly to request an update on the claim’s status.

Following up on a claim with insurance payers

When reaching out to an insurance payer, providing the representative with the correct information and taking note of what was discussed can lead to a quicker resolution. 

During the call, request to speak with a live representative and reference the claim by its claim number, not its clearinghouse reference number. The claim will have both numbers listed on the top right corner:

Note: Insurance payers won’t be able to locate the claim using the clearinghouse reference number.

It’s possible the claim will only have a clearinghouse reference number. If there isn’t a claim number, you can provide the following information instead: 

  • The client’s member ID (listed in box 1a)
  • The date(s) of service listed on the claim (listed in box 24a)

When speaking with the representative, take note of the following call details: 

  • The representative’s name
  • The call reference number
  • The number called

Taking note of this information and submitting a help request can be helpful if further investigating with our clearinghouse is needed.

Issues that can lead to a claim being stuck in the Accepted/Received status

When speaking with a representative, they may explain that the claim is still being processed, in which case no further action is needed. 

If the representative isn’t able to locate the claim using the information you’ve provided, one of the following may have taken place: 

  • The claim was submitted to the incorrect Payer ID
    • In this case, the payer wouldn’t have received the electronic submission. If you’re not sure which Payer ID should be used, submit a help request and we’ll be happy to provide the correct Payer ID. 
    • Once the correct Payer ID is determined, see Resolving claims submitted to the wrong payer for instructions on how to properly resubmit the claim. 
  • The client information listed on the claim wasn’t found in the payer’s member database 
    • This typically results in an immediate rejection of the claim, but can also take place after it’s been accepted/received. 
    • In this case, work with the payer to make sure that the client’s insurance plan is active for the date(s) of service on the claim, and that they’re eligible for coverage based on the services rendered. You can also check with the representative if any of the client’s demographic information needs to be updated. 

If you’ve confirmed that the client’s plan was active for the date(s) of service and that all of their demographic and plan information was entered correctly, and the payer is still unable to locate the claim, take note of the relevant call details, including: 

  • The representative's name
  • The call reference number
  • The number called
  • What was discussed

Then, submit a help request and include all of the call details. We’ll work with our clearinghouse to determine why the claim wasn’t processed and what needs to happen next. 

Important: Unless proof is provided showing that you reached out to the payer first, the information they’ll share with our clearinghouse is limited. This is why it’s important to provide our team with the call details before we can investigate the issue. 

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