What do payer statuses mean?


Healthcare claim statuses are given by an insurance payer to provide a physician, clinic, or a patient an update on what the payer's status is for the submitted insurance claim.  In AveaOffice, statuses represent a more detailed description of where a claim is at in the lifecycle.

Payer status can be found in:

  • Records Center > Insurance Claims > Claims, in the Payer Status column
  • Claim ID > Instances, in the Payer Status column

Type of Statuses

Accepted Status where the payer has accepted receipt of the claim.
Pending Status where the payer is reviewing the claim, pending a decision of additional review, rejection, approval or payment of the claim.

Status where the payer has denied payment of the claim due to reason(s) explained on the explanation of benefits (EOBs) or electronic remittance advice (ERAs).

There are several reasons why a payer would reject a claim.  A few examples are:

      1. Incorrect patient information or coding on claim
      2. NPI number not on file
      3. Benefits not covered by the plan
      4. Patient is not eligible for benefits
None There is no status for the claim. This could be because the payer did not provide any statuses for the claim(s), or the file which contains the status data was not set up properly between the payer, clearinghouse, and AveaOffice.


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