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Claim statuses after allocation

After allocating an insurance payment to one or more charges on a claim, the status of the claim is updated automatically.

The status that the claim receives depends on what allocations or EOB processing transactions were made to the charge(s) on the claim.

There is no separate window to manually set the status of the claim.

Allocation & EOB Processing ScenarioEffect When PostedClaim Status Becomes

Charges fully paid.

  • Payment allocations posted.

Completed

Charges partially paid or not covered, and balance is adjusted.

  • Payment allocations posted.
  • Adjustments posted.
  • Note: If insurance provides no coverage, that is processed by entering 0 into the Paid Amt and adding a Reason Code. Denial Codes are used when a claim is denied for errors on the claim that can be corrected for re-submission.

Completed

Charges partially paid or not covered, and balance is transferred to the patient.
  • If partially paid, payment allocations posted.
  • Patient owes transferred amount as of today, not from the original charge date.
  • Note: If insurance provides no coverage, that is processed by entering 0 into the Paid Amt and adding a Reason Code. Denial Codes are used when a claim is denied for errors on the claim that can be corrected for re-submission.

Completed

Charges partially paid or not covered, and balance is transferred to secondary insurance.

  • Secondary claim auto-generated.
  • If partially paid, payment allocations posted.
  • Secondary insurance owes transferred amount as of today, not from the original charge date.
  • Generates a new secondary claim automatically.
    • The new claim appears in the appropriate electronic or paper claim queue to be approved and submitted with the next batch.
    • The text "Secondary Claim" is in the remarks field with the full charge amount(s) on the claim.
    • The secondary claim is linked to the predetermination for the secondary policy if one exists.
    • Only procedures from the primary claim can exist on the secondary claim.¬†Procedures cannot be added to secondary claims.¬†

    • The EOB from the payment batch is automatically attached to the secondary claim for paper claims.
  • Note: If insurance provides no coverage, that is processed by entering 0 into the Paid Amt and adding a Reason Code. Denial Codes are used when a claim is denied for errors on the claim that can be corrected for re-submission.

Completed

Charges all denied by using the Denial Code column.
  • No payment allocations posted.
  • Insurance still owes the full balance.
  • You can correct the claim details and then create a claim again with the same procedures from the Create a Claim button in Patient > Financials.
  • The new corrected claim is linked to the denied claim, so you can view the denied claim's details from History in the Claims tab.
  • Note: Denial Codes are used when a claim is denied for errors on the claim that can be corrected for re-submission. If insurance simply provides no coverage, that is processed by entering 0 into the Paid Amt and adding a Reason Code.¬†
Denied

Charges partially paid, and the rest were denied by using the Denial Code column.

  • Payment allocations posted for covered charges.
  • Insurance still owes the balance on the denied procedures.
  • You can correct the claim details for the denied procedures and then re-submit a claim again from the Claims tab in Patient > Financials.
  • The re-submitted claim will only include the denied procedures from the first claim.
  • The re-submitted claim is linked to the partially paid claim, so you can view the partially paid claim's details from History in the Claims tab.
  • Note:¬†Denial Codes are used when a claim is denied for errors on the claim that can be corrected for re-submission. If insurance simply provides no coverage, that is processed by entering 0 into the Paid Amt and adding a Reason Code.

Partially Paid

Insurance overpaid and the overpayment is processed as patient credit.

  • Payment allocation posted.
  • Overpayment amount posted as a Patient Credit visible from Patient > Financials.
  • The credit is reflected on the patient's balance.
  • The credit can be viewed and allocated to any future patient charges from the Pt. Payments tab in Patient > Financials.

Completed

Insurance overpaid and the overpayment is processed as insurance credit.
  • Payment allocation posted.
  • Overpayment amount posted as an Insurance Payer Address credit visible from Practice > Payments > Insurance Payer Credit.
  • The credit can be used on a future EOB or refunded to insurance.
  • To learn more about refunds, see¬†Process an insurance refund.
Completed

Insurance overpaid and the overpayment is processed as insurance partial refund.

  • Payment allocation posted.
  • Overpayment amount appears as an Insurance Payer Address credit in Practice > Payments > Insurance Payer Credit.
  • The credit is marked as being intended for refund to insurance.
  • After allocation, you can process and post the overpayment refund to insurance.
  • To learn more about refunds, see¬†Process an insurance refund.

Completed

Insurance overpaid and the overpayment is processed as insurance full refund.

  • Corrective claim auto-generated.
  • No payment allocations posted.
  • Insurance still owes the balance on the procedures.
  • Overpayment amount appears as an Insurance Payer Address credit in Practice > Payments > Insurance Payer Credit.
  • The credit is marked as being intended for refund to insurance.
  • After allocation, you can process and post the overpayment refund to insurance.
  • To learn more about refunds, see¬†Process an insurance refund.
  • A corrective claim is auto-generated with the text "Corrective Claim" in the remarks field and the correct charge on the claim.
    • This claim pops up as a PDF when you save the allocation, so that you can immediately print the corrective claim.
    • The corrective claim is automatically marked as approved and submitted as its own batch, so you don't have to process it separately.
    • The new corrective claim is linked to the original returned claim, so you can view the returned claim's details from History in the Claims tab.
  • Overpayment scenario example: If the original $120 charge was adjusted to $100 after the claim was submitted, then the EOB will show an insurance payment based on the $120¬†incorrect¬†fee. The auto-generated corrective claim will show the correct $100.

Returned

If both a transfer and adjustment are selected for the same line, the action based on the transfer will take precedence.

  • For example, insurances pays $120 of an expected $200. Of the remaining $80, $60 is transferred to the patient, and $20 is a contractual adjustment. The claim status becomes Completed.
  • These 3 transactions are all entered on the same line, so you don't have to go through the entire workflow multiple times, but the transfer is processed first.

To view the history of a claim and its status changes, go to Patient > Financials > Claims and select History on the claim you want to investigate.