How Claim Status Categories are Defined

Version 14.8

If your office is contracted for Full HIPAA Services and your office contracted with a supported clearinghouse, you will have the ability to view claim status within OP.

The most frequent Claim Status Categories are as follows:

  • Q0: defined as a claim that has not been transferred to the transmittal queue so has not been electronically transmitted to your clearinghouse or printed on HCFA. 
  • Q1: defined as a claim that has been transferred to the transmittal queue but has not been electronically transmitted to your clearinghouse or printed on HCFA yet. 
  • Q2: defined as a claim that has been transferred to the transmittal queue and has either been electronically transmitted to your clearinghouse (but not yet acknowledged by your clearinghouse).
  • Q3: defined as print on a paper HCFA.
  • A0: defined as a possible claim rejection by OP and/or your clearinghouse; requires further research and may require correction and resubmission.
  • A1: defined as a claim accepted/acknowledged by your clearinghouse on initial submission.
  • A2: defined as a claim accepted/acknowledged by your payer on initial submission. 
  • A3: defined as a claim rejected by OP and/or clearinghouse; requires correction and resubmission.

When reviewing claim status, please be aware of the following Claim Status Guidelines

  1. All successfully acknowledged claims should be reaching an A1 or A2 status with the exception of selfpay and paper claims. For both selfpay and paper claims, a Q2 status is acceptable. 
  2. Any electronic claims remaining in Q0, Q1 or Q2 status AFTER acknowledgement reports are processed into OP should be transferred back to the queue for retransmission to your clearinghouse. 
  3. Any electronic claims remaining in A0 or A3 status should be reviewed, corrected and transferred back to the queue for retransmission to your clearinghouse. To determine if an A0 is a valid entry in terms of truly being forwarded to another entity, check the claim status history details (click on the claim, click on the plus sign to the left and make sure you are viewing status history). If there is no entry in the notes field AND you can verify that your clearinghouse has acknowledged receipt of this claim, then A0 is most likely a valid entry. If, however, there is some text in the notes field referencing invalid data OR if your clearinghouse cannot acknowledge receipt of the claim, then the A0 claim needs to be corrected and resubmitted to your clearinghouse. 
  4. Claims in A1 or A2 status do represent successful clearinghouse acknowledgement upon initial submission. All clearinghouses, however, do have levels of claim review. A claim may be initially acknowledged as accepted in level 1 (as represented by the A1 or A2 status in OP), however, the same claim may be rejected in the level 2 review by the clearinghouse. Level 2 (or higher) rejections will be reported by your clearinghouse on their website and will not be represented in OP. 
  5. All users should be regularly checking their clearinghouse claim status to identify rejected claims. In addition, all users should be regularly reviewing their open claims (accounts receivable) to identify claims that are outstanding where payment from the payer is overdue. Regularly assessing open claims will assist a user in minimizing issues of timely filing. 

There is an extensive list of claim status categories but for the purposes of OP, the following is a bit more comprehensive listing of most commonly reported statuses (dependent on your clearinghouse and payer mix):

  • A0: Acknowledgement-Forwarded to another entity
  • A1: Acknowledgement-Received
  • A2: Acknowledgement-Accepted for adjudication
  • A3: Acknowledgement-Returned as unprocessable
  • P0: Pending
  • P1: Pending-In adjudication process
  • P2: Pending-Suspended for review
  • P3: Pending-Waiting for requested information
  • P4: Pending-Waiting for patient response
  • F0: Finalized-Complete
  • F1: Finalized-Paid
  • F2: Finalized-Denied
  • F3: Finalized-Revised
  • F3F: Finalized-Paid/forwarded
  • F3N: Finalized-Paid/not forwarded
  • F4: Finalized-Complete, no further payment
  • Q0: Current, not queued
  • Q1: Queued for transmission
  • Q2: Transmitted/printed