About Claim Report Statuses
Use claim reports to view metrics for pending, rejected, acknowledged, accepted and completed claims included in a run.
Claim reports are used to view details of claims in the following statuses:
| Status | Description |
|---|---|
| Pending | The initial claim status. These are claims received in the gateway by RCM systems & data is imported into EDI DB. There is no status received from downstream payers, intermediaries like CHC or end payers like BCBS. Also, these claims have not been rejected by EDI edits and may or may not have been sent to the payer. If they are sent, EDI has not heard back on their status yet. |
| Rejected | Claim status will be changed to Rejected either by athenaEDI Clearinghouse edits, or by the payers. These rejections are occurring prior to the claim being accepted into the adjudication system. Typical reasons for claims to be rejected may be, but not limited to, missing or incorrect content, credentialing, eligibility, etc. note: When exporting a claim report, claims in a status of rejected (RJ), show the ANSI Reason and Status Message associated with the stataus RJ only.
|
| Acknowledged | Claims acknowledged by payers or clearinghouse on receipt. |
| Accepted | Claims accepted for adjudication by end payers or clearinghouse on passing the initial edits. |
| Completed | If a claim/charge is resubmitted, aEDI will automatically move it to a completed status. The customer can also move claims to this status. One use case for moving the status to complete is if the only way to fix a claim is to drop it to paper. Since the paper does not come through our clearinghouse, if this status needs to be updated, it must be done manually. |
The Claim Reports dropdown consists of two standard reports:
- Pending Claims for last 7 days - This report can assist with pending claims review. Pending claims may not have been received by the payer. This report will help to investigate claims to determine if further action is needed to facilitate payment.
- Rejected Claims for last 7 days - This report is used to view the status history message of the claim which helps to identify why the claim was rejected. Any necessary change(s) can then be made in your practice management system and the claim re-queued for submission.
note: For Group Management clients the Charge Number displays, not the Claim Number.
Other claim reports are:
- Clean Claim Report
- Rejection Summary and Trend Reports
- Unpaid Claims Tracker Report
- Warning Received Report
Claim reports are also used to manually update a claim's status to completed or status message.