Manually Remove Rejected Claims

If you've received a rejection, but the claim is actually being processed by the payer, you can manually remove the rejection from the Work Center. 

Common scenarios for invalid rejections: 

• The claim was rejected at the clearinghouse, but a user has confirmed receipt of the claim in the payer's system.
• The claim needs to be physically mailed by the provider with medical records attached.
• The claim will be physically mailed by the provider with certified mail tracking.

Should I correct the claim or change the claim's status?

This list includes common rejection examples where the recommended solution is to correct the claim rather than remove the claim from the Work Center by editing the payer status.

• COB Issue: If the claim is rejected for an invalid member name or ID, and it is determined that coverage is termed, it is recommended to check with the patient or provider for other coverage. If other coverage is found, we advise adding an insurance set for the new coverage dates and correcting the existing claim. If no other coverage is found, we advise voiding the claim from AveaOffice.
• Voiding Claim: If the claim was rejected and the user determines that the claim should not have been billed in the first place, we recommend voiding the claim from AveaOffice.

Manually Remove Rejections

Managing Organization Admin users can manually remove these rejections from the Currently Rejected/Held Claims tab of the Work Center by updating the Payer Status.

1. Navigate to Work Center > Insurance Claims > Currently Rejected/Held Claims.
2. Locate the claim and click the Edit Payer Status link.
3. Use the Payer Status drop-down to select a new status.
   

• Accepted: This is the most commonly selected status. We recommend using this status for all cases where the claim has been received by the payer. 
• Canceled: This status should only ever be seen if the batch or claim processing was requested to be canceled with the clearinghouse support team. Please contact [e-mail] if you see claims in "Canceled" status.
• Denied: The claim has been denied by the payer.
• Held By Payer: This is one of the statuses that directs the claim to the Currently Rejected/Held Claim queue. When payers mark a claim as Held By Payer, they will likely be reaching out for further documentation such as medical records. 
• Held By Repricer: The claim is on hold by the repricing agency.
• Name Matching: When claims are in this status, it is generally the first time that a claim has been sent to a payer ID. Avea Support will match this claim on your behalf.
• None: This status may indicate that the claim has not been received by the clearinghouse at all. Please contact [e-mail] if you see claims in the None status.
• Pending: The claim is pending processing at the clearinghouse.
• Rejected: This is one of the statuses that directs the claim to the Currently Rejected/Held Claim queue. When a claim is marked as Rejected, the processing event message will determine the best next steps to correct the claim.
• Click Save to apply the new status. 
• This will manually set the clearinghouse status of the claim so that it will be removed from the Currently Rejected/Held Claims list.

It is important to note that this payer status is also tied to how AveaOffice manages interim bill types. Please follow the recommendations (e.g., setting the status to Accepted) for how to edit the payer status effectively so that future claims or corrections may continue to process correctly for the patient.

Resetting Payer Status

If the payer status has been inaccurately set, it can be reset from the Records Center. 

1. Go to Records Center > Insurance Claims > Claims.
2. Select the Organization from the drop-down.
3. Click Update.
4. Find the claim that you need to update to the correct status. On the far right, click Edit Payer Status to update the payer status.
5. Select the Payer Status and click Save.