What steps should I take when, after calling a payer, they indicate they have not received my claim even though it shows a received or accepted by payer status?

Claim Not on File

When a claim shows a status of "None" or "Original Claim Processing", but through a follow-up conversation with the payer, you learn they cannot locate your claim, check the processing events for the claim in AveaOffice.

Select the claim ID then go to Processing Events.

• • If the latest processing event states the claim was received by the payer, try resubmitting the claim.
  • If the latest processing event states the claim was rejected, review the rejection message to correct the claim via UB-04 or CMS-1500 box number and resubmit.
  • If there are no processing events, open a ticket via email at [e-mail] or call [phone], opt #2.  Please include as much detail as you can so we can quickly find a resolution.
    • Detail to include on support ticket
      • Claim Number(s)
      • Patient Profile URL
      • Payer Contact Details
      • Call Reference Number
      • No patient health information (PHI)
      • Summary of call with the payer
      • Any unique or pertinent details of why the claim is missing, i.e. payer system outage.

Resubmission Options

Once it has been determined why the claim was not received by the payer, there are several options to take depending upon the payer:

1. Resubmit the electronic claim via AveaOffice
2. Send a paper claim via AveaOffice
3. Print and fax the claim

Follow-Up

Set a follow-up date on the claim for 2-3 business days from submit so the claim will show in Work Center > Work Claims. Add a note to remind yourself to check that the claim was received by the payer via processing events, the payer portal, or a phone call to the payer.

Notes and Documentation

Document in the claim notes why the claim was not initially received by the payer. This step is critical for future follow-ups. Insurance companies are known for not paying on claims due to timely filing. Document the cause, including the POTF details and payer contact information - including call reference numbers. 

Tag the claim with an Issue Type tag to state the reason for the claim processing delay. Use this issue type tag to track similar trends in reporting.

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Issues

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