A Claim Is Rejected or Stuck in Processing

Start on the claims list and set the status filter, which has three values: Processing, Rejected and Accepted. Every claim is in exactly one of them, so between the three you are seeing your whole book.

What the three actually mean

• Accepted - the payer took the claim in. It does not mean paid. A claim can sit accepted for weeks and then pay nothing.
• Rejected - it came back. There will be a reason; see below.
• Processing - anything else, including claims that have not been sent yet. This is the bucket that hides problems, because "not sent at all" and "sent and awaiting a response" look the same here.

A claim was rejected

Open it. The rejection text is recorded on the claim, and it is specific - a payer will name the field it did not like. Read it before changing anything, because most rejections are one wrong value rather than a broken claim.

The usual causes, roughly in order:

• Patient identifiers - name, date of birth or member ID not matching the payer's record. A middle initial or a maiden name is enough.
• Coverage - the policy was not active on the date of service.
• Missing prior authorisation - add it under Other Fields.
• Diagnosis and service mismatch - the codes do not support each other.
• Provider details - NPI or taxonomy wrong for that payer.

Correct the underlying record rather than the claim where you can - a wrong member ID will reject the next claim too. Then use Re-Create Claim Document so the claim is rebuilt from the corrected data, and send it again.

If every claim to one payer rejects the same way, stop fixing them one at a time. That is an enrolment or a payer ID problem, and it will keep happening.

A claim has been Processing for weeks

First check whether it was actually sent. A claim that was created and never submitted sits in Processing indefinitely and no one is waiting on it but you.

Then use the age filter. Current is the first 30 days since submission; the older buckets are where genuine problems live. Anything past 30 days with a balance deserves a call to the payer - quote the claim and, if you have one, the ERA ID.

Note the age is counted from the date the claim was sent, not the date of service. A claim submitted late looks young here even when the visit is months old.

I cannot find a claim in any aged view

The aged views only show claims with a balance outstanding. A claim paid in full drops out of all of them - so a claim that seems to have vanished has usually been settled.

Clear the age filter, or search for it directly, before concluding anything is missing.

The claims list is empty

No records found nearly always means the filters, not the data. Status, age range and date range all apply at once, and Current plus a narrow date range excludes most of a practice's claims. Use Clear and start again with one filter.

The insurer paid but the claim still shows a balance

• Check the ERA was posted. Money that arrived is not applied until the remittance is processed.
• Look at Adjustments / Discounts - a contractual write-off may not have been taken.
• The remainder may legitimately be the patient's, or the secondary insurer's.

Judge the claim by Claim Balance on the claim itself. It is calculated from the services and the payments actually recorded, and it is what the aged views use.

Nothing arrives when I check for ERAs

Almost always ERA enrolment for that payer has not completed. Sending claims and receiving remittances are separate enrolments, and payers can take weeks over the second one. Until it is live, that payer's payments arrive on paper and are posted with Process Payer Payment.

What to have ready before contacting support

The claim, the payer, the date of service, the rejection text as written, and the ERA ID if a remittance is involved. The rejection text is the part that shortens the conversation most - a paraphrase usually loses the field name that identifies the cause.