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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 will vary from payer to payer. You may see certain insurers paying in a matter of days, while others could take a few weeks. However, if you ever notice that you have not received a status update on a claim in over 30 days, or if you notice a delay in the average processing time for that insurer, we recommend reaching out to the payer directly to request more information on the claim's current status.

If you are not enrolled to receive payment reports, the Received or Accepted status could be the last piece of information the payer shares with our clearinghouse as you should receive an Explanation of Benefits once the payer has finished processing the claim.

Payers vary in the amount of information each shares with our clearinghouse as some payers do not send accepted acknowledgements. The received acknowledgement is sent to our clearinghouse once the payer has received the claim.  Even though the payer has sent a received or accepted acknowledgement, sometimes automated systems and payer portals may not be able to locate the claim as claims usually in batches prior to being accepted for processing (similar to credit card processing).  The accepted status usually is paired with a payer claim number (if that information is something the payer shares with our clearinghouse) and lets SimplePractice know the claim has been accepted in to the payer's adjudication process.

When a claim has been in the "Accepted" state for a prolonged amount of time or for more than 30 days, this can indicate that there was an issue with the claim that does not make it eligible for reimbursement. However, the amount of information that the payers share will vary, so our clearinghouse isn't always notified of a rejection or denial.

Note: Keep in mind that when filing claims electronically, the claim will go through processing by several parties. At each of these transmission points, the amount of information each party shares with our clearinghouse, and in turn SimplePractice, will vary. For a visual representation of the journey that your electronic claim submission will take, please refer to the following infographic: How do I get paid for insurance claims?

In cases like this, if you notice that you have not received a status update in several weeks after submitting a claim, or if the claim has reached the accepted state but has not been assigned a payer claim number, you will want to reach out to the payer directly by calling their Provider Services number.

During this call, we recommend:

  • Requesting to speak directly with a live representative
  • Referencing the claim using:
    • The member ID number (exactly as it is listed on the claim submission)
    • The dates of service listed on the claim
  • Taking note of the call details (including the representative's name, the call reference number, and the number called) 

Important: The payer will not be able to locate a claim if it is referenced by the Clearinghouse Reference ID number.

While there can be rare instances of network-wide issues that prevent the transmission of electronic claims, our clearinghouse has reliable connections with all payers that they work with and are aware of any events that could cause claims not to be successfully submitted. 

If the payer's rep is not able to locate the claim(s) based on the client’s member ID or DOS, it is likely that either:

  • The claim was submitted to the incorrect Payer ID for the client's insurance plan: This would cause the payer not to receive the electronic submission.
    • If there's ever any question of where your claims should be submitted, you can reach out to our Customer Success team, and we will be happy to provide the appropriate Payer ID number.
    • If you know which payer the claim needs to be submitted to, see What should I do if I submitted a claim to the wrong payer? for instructions on how to properly resubmit a claim
  • The insured's information listed on the claim was not found in the payer's member database: This could've resulted in an immediate rejection, in which case, the claim never entered the payer's claims database.
    • We recommend following up with the payer to ensure that the client's benefits plan was active for the DOS on the claim, and that they are eligible for coverage based on the services rendered. You can also check 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 billed dates of service, that all of their demographic information was entered correctly on the claim submission, and that the Payer ID number was correct for their insurance plan, and the payer is still unable to locate the claim submission, please take note of the relevant call details. This includes:

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

Then, if you write in to our Customer Success team and include all of the call details, our clearinghouse will be able to follow up with the representative to sort out why the payer sent the "Accepted" status, but shows no record of the claim.

Note: Please be aware that without the provider's party reaching out first, the payer will only share very limited information with our team at the clearinghouse.


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